Marine Immersion Student questionnaire NAME: Home town/high School:

Transcription

1 Marine Immersion Student questionnaire Please return to Jessica Bolker: Department of Biological Sciences, 216 Rudman Hall, 46 College Rd., Durham NH or or (fax) NAME: Home town/high School: What is your background in biology? Marine biology? Have you taken summer courses or had other field or research experience? (what, where, when?) Are there any health or other physical issues that might affect your ability to do moderately strenuous fieldwork (climbing around on rocks, carrying buckets of water)? (These do not disqualify you from full participation in the course; it will just be helpful to everyone if I know in advance. Food allergies and other dietary limitations are readily accommodated at SML with advance notice.) MImm student questionnaire p. 1/2

2 What area of biology, or group of organisms, do you know the most about and how did you acquire that knowledge? What do you consider your strongest skills, academically and otherwise? What do you want to learn during Marine Immersion, and more generally? What is your greatest concern about this class? What would you like to be able to say about Marine Immersion at the end of the course? What are you reading right now (or what is the last book you read)? What do you want to read next? (not necessarily science books!) What is a specific thing that your good friends know about you, but that someone meeting you for the first time would not necessarily realize right away? (something you don t mind sharing I need this info for a trivia game.) Anything else you d like us to know up front: MImm student questionnaire p. 2/2

3 H ealth H i story f orm f or Shoal s M ari ne Laboratory on A ppl edore I sl and, M ai ne, 2016 Pl ease com p l et e and r et ur n t hi s f or m w i t hi n 10 bu si ness d ay s of r ecei v i ng i t f r om Shoal s: M ai l : Jessi ca Bol k er : D ep ar t m en t of Bi ol ogi cal Sci en ces, 216 Ru d m an H al l, 46 Col l ege Rd, D u r h am N H / Fax: (603) Pl ease PRI N T al l of y ou r r esp on ses. The i nf or m at i on p r ov i d ed bel ow w i l l be on l y be u sed by Sh oal s M ar i n e L abor at or y (SM L ), Cor n el l U n i v er si t y, t h e U ni v er si t y of N ew H am p sh i r e (U N H ) and appr opr i at e m ed i cal per son n el. Th e i n f or m at i on w i l l n ot be r el eased ou t si d e of SM L, Cor n el l, U N H and em er gency r esp ond er s w i t hou t y ou r w r i t t en p er m i ssi on. Personal I nf ormati on (requi red) N am e of p ar t i ci p an t : D at e of Bi r t h : Par t i ci p ant cel l p hone: Par t i ci p an t em ai l : Par t i ci p an t m ai l i n g ad d r ess: Emergency Contact I nf ormati on (required) N am e of em er gen cy con t act (Par en t, L egal Gu ar d i an ): Rel at i onsh i p of em er gen cy con t act t o p ar t i ci p an t : Em er gen cy con t act p h on e: Em er gen cy con t act em ai l : I nsurance I nformati on (requi red) N am e of I n su r an ce Com p an y : Pol i cy n u m ber : Pol i cy hol d er s nam e: Rel at i onsh i p t o p ol i cy h ol d er : G eneral H ealth and M edi cal I nformati on (requi red) Pl ease i n d i cat e bel ow any exi st i n g or p r ev i ou s m ed i cal con d i t i on s (p h y si cal an d / or m ent al ) t hat m ay r equ i r e sp eci al at t ent i on (e.g. ep i l ep sy, ast hm a, hand i cap, an xi et y, d ep r essi on, et c.). U se ad d i t i on al p ages i f n eed ed. A l l er g i es an d d i et ar y / f ood p r ef er en ces i n n ex t sec t i on.

4 I nf ormati on about Allergies and/or Allergic Reactions (requi red) A l l er gi es t o m ed i cat i on s: O t h er en v i r onm ent al al l er gi es ( e.g. bee st i n gs, et c.) : Food r el at ed al l er gi es; p l ease be sp eci f i c (e.g., i f seaf ood, w hat t y p e; i f nu t s, w hat k i nd?). Ou r k i t chen st af f n eed s t h i s i n f or m at i on t o best ser v e y ou r n eed s: D i etary Requi rements/pref erences (requi red) Pl ease be sp eci f i c; ou r k i t ch en st af f n eed s t h i s i n f or m at i on t o best ser v e y ou r n eed s. I n d i cat e v eget ar i an, v egan, l act ose i n tol er an t, gl u ten -f r ee (f ood al l er gy or p r ef er en ce?), et c: Prescri pti on I nf ormati on (required) Pl ease l i st an y p r escr i p t i on s t h at y ou w i l l be br i n gi n g w i t h y ou (p l ease be sur e t o br i n g a suf f i ci en t suppl y if ap p l i cabl e al so see bel ow *): Pl ease l et u s k n ow i f an y p r escr i p t i on s or ot h er m ed i cat i on s y ou ar e br i n gi n g (sp eci f y ) n eed t o be r ef r i ger at ed : *Pl ease n ot e: I n t h e ev ent t hat any of y ou r p r escr i p t i ons need t o be r e-f i l l ed, or a n ew p r escr i p t i on i s n eed ed becau se of an em er gen cy, p r escr i p t i on s n eed t o be cal l ed i n t o: CV S Ph ar m acy, 674 I sl i n gt on St r eet, Por t sm ou t h, N H 03801; Pr escr i pt i on pay m en t s m ust be pr epai d by cr edi t car d, d i r ectl y to t h e p h ar m acy p r i or t o p i ck -u p by an SM L st af f m em ber. You w i l l n eed t o i n d i cat e t o t h e ph ar m acy t h at SM L st af f h as y our per m i ssi on t o pi ck up t h e pr escr i pt i on. W i l l an y of y ou r p r escr i p t i on s ( p l ease sp eci f y ) n eed t o be ad m i n i st er ed by a n u r se or d oct or?** Ci r cl e on e: Yes / N o **I f so, w e w i l l h av e t o n ot i f y m ed i cal p er son n el on n ei gh bor i n g St ar I sl an d. You r si gn at u r e on p age 2 w i l l al l ow u s t o d o so. A uthori zati on f or M edi cal T reatment and Permi ssi on to D i scl ose M edi cal Records (requi red)

5 I her eby author i ze a st af f r epr esent at i v e of the Shoal s M ar i ne L abor ator y to act on my behal f i n t he ev ent that I becom e i l l or i njur ed and unabl e to pr ov i d e i nf or med consent for med i cal t r eat ment. I f ur t her aut hor i ze a Shoal s st af f r epr esent at i v e t o ad m i ni st er or secur e pr oper emer gency tr eatment, i ncl udi ng x-r ay, exam i nat i on, anestheti c, m ed i cal, sur gi cal, or t r eatment, and / or hospi tal car e, to be r ender ed under the super v i si on and on the advi ce of a l i censed physi ci an or sur geon as appropri ate, duri ng the peri od the regi strant i s enrol l ed i n Shoal s M arine Laboratory s summer program. In the ev ent of a m ed i cal emer gency, SM L w i l l m ak e a good f ai th ef f or t t o cont act a par ent, l egal guar d i an or em er gency cont act as soon as possi bl e. I und er st and that i t m ay be necessar y f or SM L t o d i scl ose my m ed i cal r ecor d s and per sonal i nf or m at i on t o SM L st af f m em ber s and to any one i nv ol v ed i n my medi cal car e that needs the i nf or mati on (e.g., physi ci ans, hospi tal s, emergency personnel, or other per sons or enti t i es i nv ol v ed i n pr ov i d i ng m ed i cal car e or assi stance) on a r easonabl e need -to-k now basi s. Par t i ci pant si gnatur e (d at e) Pr i nt par t i ci pant name, and emai l Parent/ Guardi an si gnature (requi red i f par ti ci pant i s a mi nor/ under 18) (d at e) Pr i nt Par ent / Guar d i an nam e, and emai l (r equi r ed i f par ti ci pant i s a mi nor / under 18) A uthori zati on f or di spensi ng over the counter M edi cati on to M i nors (under 18) I her eby author i ze a st af f r epr esent at i v e of the Shoal s M ar i ne L abor at or y to pr ov i d e ov er the counter medi cati on i n the ev ent of any mi nor di scomf ort that shoul d ari se w hi l e at SM L, e.g. Tyl enol (or a gener i c br and) f or a headache, Pept o Bi sm ol (or a gener i c br and) f or a stomach ache, Sud af ed (or a gener i c br and) f or a r unny nose, Boni ne (or a gener i c brand) f or moti on si ckness, etc. Parent/ Guardi an si gnature (requi red i f parti ci pant i s a mi nor/ under 18) (d at e) Pr i nt Par ent / Guar d i an nam e, and emai l (requi r ed i f par t i ci pant i s a m i nor / und er 18) (d at e)

6 Code of conduct and social ethics form for Shoals Marine Laboratory on Appledore Island, Maine Please complete and return this form as soon as possible to: Jessica Bolker, Department of Biological Sciences, 216 Rudman Hall, 46 College Rd, Durham NH / Fax: (603) Since 1966, Shoals Marine Lab has been conducting rigorous academic programs offering participants a chance to experience marine science and related subjects in a remote field station setting. One of the hallmarks of this experience is the enduring sense of community that occurs between our participants, faculty and staff, due to our isolated island environment. You should decide to participate in Shoals Marine Laboratory only if you are committed to maintaining the highest academic and social standards. As a member of the Shoals community, you are expected to behave in a responsible manner, and to be courteous and respectful to fellow participants, faculty and staff. Academic Rules and Regulations: The following rules and regulations are strictly enforced. Violation will result in a hearing with faculty and the Director and may result in legal proceedings at the Federal/State level. Continued enrollment is at the discretion of the Director. Participants dismissed from the program are not entitled to a refund of course costs, and will be required to leave Appledore Island immediately. Participants will not engage in: Behavior that is offensive, disruptive or dangerous to other participants, faculty and staff. Active or passive harassment/discrimination based on race, color, creed, religion, national or ethnic origin, sex, sexual orientation, gender identity or expression, age, disability, or veteran status. Plagiarism or any form of academic dishonesty. Possession of weapons or fireworks. Downloading of illegal materials. Participants will: Abide by the drug and alcohol policies of the Shoals Marine Laboratory. Treat the physical and biological environment of the island, including SML buildings, furniture and equipment, with care and respect. Abide by all applicable federal, state and town laws. Attend class regularly and participate fully in all courses in which they are enrolled. Your signature indicates that you have read these rules and regulations and agree to abide by them. Participant signature Print participant name, and Parent/Guardian signature (required if participant is a minor/under 18) Print Parent/Guardian name, and (required if participant is a minor/under 18)

7 Multimedia agreement and release form for Shoals Marine Laboratory on Appledore Island, Maine Please complete and return this form as soon as possible to: Jessica Bolker, Department of Biological Sciences, 216 Rudman Hall, 46 College Rd, Durham NH / Fax: (603) I, have been informed and subsequently understand that the Shoals Marine Laboratory (hereinafter referred to as SML), which is a joint partnership between Cornell University and the University of New Hampshire, continuously updates its multimedia products, including, but not limited to: web content, broadcast television, educational productions, and printed promotional materials in which my name, likeness, image, and/or voice may be included. 2. I hereby grant SML and its employees and agents, the right to make, use and publish in whole, or in part, any recorded footage in which my name, likeness, image and/or voice may be included (hereinafter Recordings ) whether recorded on or transferred to videotape, film, slides, photographs, audio tape, digital format, print media or other media now known or hereafter developed. This includes, without limitation, the right to edit, mix, duplicate, use or reuse Recordings as desired without restriction as to changes or alterations. 3. I also grant SML the right to distribute, display, broadcast, exhibit, and market any of said recordings, either alone or as part of its finished productions; for commercial or non-commercial purposes as SML or its employees and agents may determine. This includes the right to use said recordings for promotion or publicizing any of these uses. 4. I hereby waive any and all rights that I may have to inspect or approve the finished product or printed matter that may be used in connection therewith. 5. I expressly release SML, and all persons acting under its permission or authority, from any claim or liability arising out of or in any way connected with the above uses and representations including any and all claims for defamation or copyright infringement. 6. I understand that I will not be named in the credits of the work, but may be named elsewhere in the work if interviewed directly. 7. I am over the age of eighteen, and have read the above release, and fully understand its contents. (Parent/Guardian Signature required if participant/student is under 18 years of age.) Participant signature Print participant name, and Parent/Guardian signature (required if participant is a minor/under 18) Print Parent/Guardian name, and (required if participant is a minor/under 18)

8 Release and hold harmless form for Shoals Marine Laboratory on Appledore Island, Maine (For participants 18 years of age or older) Please complete and return this form as soon as possible to: Jessica Bolker, Department of Biological Sciences, 216 Rudman Hall, 46 College Rd, Durham NH / Fax: (603) I Hereby Acknowledge and Agree that my participation in, and my time at Shoals Marine Laboratory on Appledore Island have inherent risks. I understand that the risk of traveling to and from the island via water vessel is present. I understand that the island surface is composed mainly of rock of which there may be no set path for walking, and which can be slippery. In addition, I agree that the island, by its nature, is surrounded by water, and as such the chance of injury associated with immersion in water or the hazards of the shoreline are present. Release/Indemnification - In consideration of my participation in, and my time at Shoals Marine Laboratory on Appledore Island, I, the undersigned, on behalf of myself, my heirs, representatives, executors, administrators and assigns, do hereby release, indemnify, and hold harmless Cornell University and The University of New Hampshire, their Trustees, officers, agents, and employees (collectively Shoals Marine Lab) from any cause of action, claims, or demands of any nature whatsoever, which I, my heirs, representatives, executors, administrators and assigns may now have, or have in the future against Shoals Marine Lab on account of personal injury, property damage, death or accident of any kind, arising out of or in any way related to my participation in Shoals Marine Laboratory programs, and my time at Appledore Island, whether that participation is supervised or unsupervised, howsoever the injury or damage is caused, other than those injuries resulting from the sole negligence of Shoals Marine Laboratory. I certify that I am in good health and that I have no physical limitations that would preclude my safe participation. I further certify that I am therefore of lawful age (18 years or older) and otherwise legally competent to sign this agreement. I understand that the terms of this agreement are legally binding and I certify that I am carefully signing this agreement, after having carefully read same, of my own free will. IN WITNESS WHEREOF, this instrument is duly executed,. Participant signature Print participant name, and

9 Parental indemnification form for Shoals Marine Laboratory on Appledore Island, Maine (for participants under 18 years of age) Please complete and return this form as soon as possible to: Jessica Bolker, Department of Biological Sciences, 216 Rudman Hall, 46 College Rd, Durham NH / Fax: (603) I Hereby Acknowledge and Agree that my child s participation in Shoals Marine Laboratory programs, and their time at, Shoals Marine Laboratory on Appledore Island has inherent risks. I understand that the risk of traveling to and from the island via water vessel is present. I understand that the island surface is composed mainly of rock of which there may be no set path for walking, and which can be slippery. In addition, I agree that the island, by its nature, is surrounded by water, and as such the chance of injury associated with immersion in water or the hazards of the shoreline are present. I agree that I will discuss these risks with my child and make sure they understand the risk involved with this activity. Indemnification/Hold Harmless - In consideration of my child s participation in Shoals Marine Laboratory programs on Appledore Island, I, the undersigned, on behalf of my child, myself, my heirs, representatives, executors, administrators and assigns, do hereby agree to defend, indemnify, and hold harmless Cornell University and The University of New Hampshire, their Trustees, officers, agents, and employees (collectively Shoals Marine Lab) from any cause of action, claims, or demands of any nature whatsoever, which I, my child, my heirs, representatives, executors, administrators and assigns may now have, or have in the future against Shoals Marine Lab on account of personal injury, property damage, death or accident of any kind, arising out of or in any way related to my child s participation Shoals Marine Laboratory programs and my time at Appledore Island, whether that participation is supervised or unsupervised, howsoever the injury or damage is caused, other than those injuries resulting from the sole negligence of Shoals Marine Laboratory. I certify that my child is in good health and has no physical limitations that would preclude their safe participation. I understand that the terms of this agreement are legally binding and I certify that I am carefully signing this agreement, after having carefully read same, of my own free will. IN WITNESS WHEREOF, this instrument is duly executed,. Date Print participant name, and Print Parent/Guardian name, and Parent/Guardian signature