Application for Eagle Hill Fall Weekend Workshops

* Denotes required fields

*Full Name
*Phone (day)
Phone (eve)
Phone (cell)
*Address
*City
*State/Province
*Zip/Postal Code
*Email

Age (for making room arrangements)

*Gender	Female Male

*Alumnus	Institute alumnus(a) 1st time applicant
I would like to participate in the following program(s):

*First title
*Instructor
*Dates

Second title
Instructor
Dates

Alternate title
Instructor
Dates
What are your specific interests, goals, and expectations for the above workshop(s)?
Which of your experiences, classes, or interests are related to the above programs? What is your current career or career interest and institutional affiliation?
Accomodations are double occupancy, but some single rooms are available. Do you have any personal habits, preferences, or concerns that you would like us to consider when assigning roommates? Which nights will you be staying at the Institute? None Friday Saturday Sunday Other (please specify): Do you smoke or snore? Smoke Snore Meal plan choice: full meal plan (required for residents: includes meals from Friday dinner through Sunday lunch) commuter meal plan (includes dinner on Friday and lunches on Saturday and Sunday) Do you have any special dietary requirements we should be aware of? No significant dietary restrictions I am a strict vegetarian I am a "vegetarian," but I do occasionally eat: dairy eggs chicken fish shellfish other animal products: I have the following allergies: Are you fully able to participate in field trips, some of which may involve hiking over uneven and/or awkward terrain? Please indicate any concerns you might have and how we might be able to help.
Do you have any special medical conditions we should be aware of?
Are you requesting a general discount? Only one of the following may be requested. Year-round resident of Washington or Hancock County (20%) Institute alumnus(a) of 1 previous seminar (10%) Institute alumnus(a) of 2-3 previous seminars (15%) Institute alumnus(a) of 4+ previous seminars (20%) University student (10%); with faculty letter of recommendation(20%) Couple (10%) Group (10%)
If you are a student, please list your university or college. If you are an alumnus, please list seminars you have attended.
Are you interested in possibly carpooling if someone inquires? Yes No If yes from where?
Other pertinent information, comments, questions, etc., are welcome:
In case of emergency, contact:
* Emergency Contact Name
* Emergency Contact Phone
* Emergency Contact Email
* Each application needs to be accompanied by a $50 deposit, which is credited towards costs for room, board, and tuition. The balances is due upon arrival at Eagle Hill. Once you click "Submit" below, you have the option to go to a secure server to pay your deposit by credit card by way of PayPal ... or ... to choose "Pay by check".
* I grant Eagle Hill Institute the permission to use any photographs taken of me during my participation in the above seminar(s) solely for the purposes of Eagle Hill Institute-related promotional material and publications. How did you hear about Eagle Hill? * I understand that during my participation in this seminar, reasonable efforts will be made to assure my comfort and safety both at the host facility and in the field. I recognize my own responsibilities in this regard. Full details on liability are available.
*Signed (type your name)
*Dated

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