Participant Application, 2016

Prepared by Aaron A. Burke (burke@humnet.ucla.edu)

Revised August 5, 2015

Instructions

Please note that this application is ONLY for those enrolling to participate in the project WITHOUT credit. If you desire to enroll for credit, please visit the UCLA Travel Study website.

Please fill in ALL of the information requested below and complete the attached medical forms and waivers. Only complete applications will be considered. Applications will be accepted until April 15, 2016. If you have any questions, please contact the academic program coordinator, Dr. Jeremy Smoak (smoak@humnet.ucla.edu).

An application must include the following completed documents:

Participant Application

Medical Status form

UCLA waiver for voluntary activity

For up-to-the-minute details regarding the Jaffa Cultural Heritage Project and upcoming events, check The Jaffa Cultural Heritage Project group page at Facebook.com.

Submit Application by Email to:

Please email your completed application and accompanying materials to the academic program coordinator, Dr. Jeremy Smoak (smoak@humnet.ucla.edu).

Notifications & Payment

Applicants will be notified of their acceptance for the program no later than May 1. Please submit $200 deposit with application. Remainder of payment should be submitted after the participant is advised of his or her acceptance but no later than May 1.

Once accepted to the program payment must be submitted by May 1. Checks should be made payable to Aaron Burke (Memo: JCHP excavations 2016) and should be mailed to:

Prof. Aaron A. Burke

NELC Dept., UCLA

415 Portola Plaza

Humanities 378

Los Angeles, CA 90095-1511

USA

Withdrawal of a participant’s application from the program will result in the forfeiture of the deposit. After May 1 there are no refunds unless the program is cancelled. In the event of the cancellation of the program for any reason prior to the program’s start date, refunds will be given in full.

Participant Information

Full Name (as appears on passport)

First Name: Click here to enter text.	Middle (if applicable): Click here to enter text.

Last Name: Click here to enter text.	Nickname (if relevant): Click here to enter text.

Permanent Address:

Street: Click here to enter text.

City: Click here to enter text. State (if relevant): Click here to enter text.	Country: Click here to enter text.

Mail Code: Click here to enter text.

Telephone no.: Click here to enter text.	Mobile no. Click here to enter text.	Fax no.: Click here to enter text.

Email: Click here to enter text.

Passport

No.: Click here to enter text.

Nationality: Click here to enter text.

Expiration date: Click here to enter a date.

Emergency Contact

Name: Click here to enter text.	Relationship to you: Click here to enter text.

Telephone no.: Click here to enter text.	Fax no.: Click here to enter text.

Email: Click here to enter text.

Personal Information

Sex Choose an item.	Age Click here to enter text. (must be 18 or older)

Height Click here to enter text.	Weight Click here to enter text.

Occupation or Field of Study Click here to enter text.

Blood Type Click here to enter text.

Physician’s Information

Name of Personal Physician: Click here to enter text.	Street: Click here to enter text.

City: Click here to enter text.	State (if relevant): Click here to enter text.	Country: Click here to enter text.

Mail Code: Click here to enter text.

Telephone no.: Click here to enter text.	Fax no.: Click here to enter text.	Email: Click here to enter text.

Diagnosed health concerns: Click here to enter text.	Allergies: Click here to enter text.

Insurance Information

All participants are expected to demonstrate that they have medical insurance coverage prior to their participation.

Insurance Provider: Click here to enter text.

Policy No.: Click here to enter text.	Group No.: Click here to enter text.

Policy expiration date: Click here to enter a date.

Other information we should know about your information: Click here to enter text.

Institutional or Occupational Affiliation

Home Institution: Click here to enter text.	Relationship to Home Institution: Choose an item.

If you know a staff member or former participant, please list: Click here to enter text.

How you heard about this project: Choose an item.

Education

Degree 1: Choose an item.	Institution: Click here to enter text.

Field of Study: Click here to enter text.	Date begun: Click here to enter a date.	Date completed: Click here to enter a date.

Degree 2: Choose an item.	Institution: Click here to enter text.

Field of Study: Click here to enter text.	Date begun: Click here to enter a date.	Date completed: Click here to enter a date.

Degree 3: Choose an item.	Institution: Click here to enter text.

Field of Study: Click here to enter text.	Date begun: Click here to enter a date.	Date completed: Click here to enter a date.

Degree 4: Choose an item.	Institution: Click here to enter text.

Field of Study: Click here to enter text.	Date begun: Click here to enter a date.	Date completed: Click here to enter a date.

Foreign Travel and Cultural Experience

Countries previously visited: Click here to enter text.

Languages spoken: Click here to enter text.

Archaeological Experience

Related courses taken: Click here to enter text.

Archaeological excavation experience (sites): Click here to enter text.

Relevant field or lab skills: Click here to enter text.

Other skills: Click here to enter text.

Reference(s)/Recommendation(s)

Please submit two letter(s) of recommendation addressing your preparation for participation in this project. The letter is due by the deadline and must be submitted directly (by email) to the program.

Name: Click here to enter text.	Relationship to you: Click here to enter text.

Street: Click here to enter text.

City: Click here to enter text.	State (if relevant): Click here to enter text.	Country: Click here to enter text.	Mail Code: Click here to enter text.

Telephone no.: Click here to enter text.	Fax no.: Click here to enter text.	Email: Click here to enter text.

Name: Click here to enter text.	Relationship to you: Click here to enter text.

Street: Click here to enter text.

City: Click here to enter text.	State (if relevant): Click here to enter text.	Country: Click here to enter text.	Mail Code: Click here to enter text.

Telephone no.: Click here to enter text.	Fax no.: Click here to enter text.	Email: Click here to enter text.

Considerations about which Staff should be Aware

Please let us know any special needs or circumstances that will help us adequately prepare for your participation in the project. Click here to enter text.