Field School Application

Personal Information

Full Name: *required

Email address: *required

Full Mailing Address:

Phone Number:

Person to Contact in Case of Emergency:

Contact Phone & Email Address:

Relationship to Applicant:

Certifications & Qualifications

Are you currently certified in CPR and First Aid? Yes No
If you are not certified, you must complete a course prior to June 18.

Occupation:

If you are a student, please indicate your:
School:

Major & Program:

Anticipated Date of Graduation:

If you are a professional archaeologist/historian/researcher, please tell us:
Affiliated Institution:

Field of Study:

Are you interested in receiving credit for this fieldschool?
Yes No

If yes, please indicate Graduate or Undergraduate:
Undergraduate Graduate

Diving History and Experience

From which recognized training organization is your SCUBA certification?
NAUI PADI AAUS YMCA SSI TDI
Other:
Date & Place of Certification:

Please enter your Divers Alert Network Number:
You must have DAN insurance by June 1 to participate. How to sign up for DAN insurance.

Please list the date, location, depth, and time of your last four dives:
1 2 3 4

Please list any prior nautical archaeology diving experience,
or any prior archaeology fieldschools or experience:

Medical History

Please let us know about any dietary requirements, food allergies, or special medical conditions:

NAUI Medical Waiver

You must complete a physical examination prior to enrollment. It must have taken place no more than 12 months prior to the start of this fieldschool, and your physician must read and sign a NAUI medical waiver. Download the NAUI waiver.

Miscellaneous

Please check the box next to EVERY statement below. If your application is accepted, upon your arrival in June, you will be asked to sign this document.

I have studied the course syllabus and information contained in the Field School description, and understand the policies, regulations, and expectations for this Field School.

I recognize that, if applicable, I am responsible for completing all academic requirements to receive credit, and that I must arrange any transfers of credit to my home institution.

I have completed a physical examination with my physician during this calendar year (2012) and have attached my completed and signed medical waiver forms.

I understand the pre-requisite requirements for SCUBA, DAN Insurance, and CPR/First Aid certification, and have provided documentation of them.

I acknowledge that I am responsible for providing and maintaining my own personal gear and equipment, as well as transportation to and from the field school, or I have already made alternate arrangements with the Field School Coordinator.

I understand that I am responsible for contacting LCMM to correct any errors or omissions, and will provide any necessary clarifications if asked.

I certify that the above information is true and complete to the best of my knowledge. I acknowledge that my application does not guarantee admission. If accepted, I promise to observe all the rules, regulations, and requirements set by LCMM to ensure both my safety and the safety of others. I further acknowledge that a violation of these, at the sole discretion of LCMM staff, may result in my dismissal from the field school without any refund of my tuition.

I grant to the Lake Champlain Maritime Museum the right to take photographs and video of myself in connection with the field school. I authorize the Lake Champlain Maritime Museum, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that the Lake Champlain Maritime Museum may use my image/voice with or without my name and for any lawful purpose, including such purposes as publicity, illustration, advertising, and Web content, without compensation. [Please note that you will not be disqualified from the field school if you do not wish to check this box.]

Please let us know where you heard about our Field School:

After submitting this application, you must email Field School Coordinator Alex Lehning at alexl@lcmm.org with the following documents [PDFs or JPEGs will be accepted] These are REQUIRED components of your application:

• SCUBA certification card
• Current CPR certification card
• Completed & Signed NAUI medical waiver
• Proof of DAN insurance