KIDS STUDYING EURASIAN NOMADS

Student

Application Form

(May also be requested by mail from the address below)

____________________________________________________

Summer 2000 Expedition to Altai Mountains, Mongolia

GirlsÕ Session (ages 14-17): July 12-29. Tax Deductible Tuition- $4,000

BoysÕ Session (ages 14-17): August 1-17; Tax Deductible Tuition- $4,000

Airfare Not included in above. Dates may be subject to slight change.

__________________________________________________________

Application and $500 deposit are due on or before April 1, 2000

Balance of tuition ($3,500) due on or before May 1, 2000

Deposit is non-refundable after the student has been accepted into the program.

__________________________________________________________

Personal Information

Name___________________________________________Birthday______________________

Address______________________________________________________________________

____________________________________________________________________________

Mailing Address if different from above_______________________________________________

____________________________________________________________________________

Home phone (_____) ____________ e-mail address ____________________________________

Sex____ Height_____ Weight_____ Social Security Number______________________________

Passport Number________________________ expires_________________ (if you do not yet have a passport, you can leave this part blank for now. Please apply for a passport as soon as possible at your local post office. You must have a passport to go on this trip).

School________________________________________________________Grade___________

Address of School______________________________________________________________

Emergency Contact (1)

Name ______________________________________________________________________

Relationship___________________ Home Address____________________________________

___________________________________________________________________________

Work Address________________________________________________________________

__________________________________________________________________________

Home Phone (____) _______________________ Cell Phone(____) _______________________

Work Phone(__) __________________ E-mail address________________________________

Emergency Contact (Please list two)

Name ______________________________________________________________________

Relationship___________________ Home Address_____________________________________

____________________________________________________________________________

Work Address__________________________________________________________________

_____________________________________________________________________________

Home Phone(__) ___________________ Cell Phone(___) _______________________________

Work Phone(__) ________________ Internet address___________________________________

Medical Conditions

Medical treatment will not be equal to the norm in the US. Please be sure to list all special medical conditions you may have.

Blood Type______Special Diet for foods_______________________________________________

Diabetes____ Epilepsy____ Asthma____ Allergies_______________________________________

______________________________________________________________________________

Other Medical Conditions_________________________________________________________

______________________________________________________________________________

Loss of Consciousness (explain and give date)_______________________________________________

Corrective Lenses/ Contacts__________ Date of last physical examination_______________________

Along with this application, please provide the following:

1. Three reference letters from adults who have known you for at least one school year. One letter must be from a teacher. (Family members do not apply).

a___________________________________________________________________________________

b____________________________________________________________________________________

c____________________________________________________________________________________

2. A one-page, single spaced, personal essay. Please supply the following information in the essay: a) tell about yourself (how would you describe yourself, interests, what would you like to do in the future, etc.) b) give 3 reasons why you want to participate in this expedition c) give 3 reasons why you think you would make a good KSEN expedition member.

3. A photo of yourself to be put on KSENÕs website.

Conditions

As a team member of the KSEN project, you must adhere to regulations and maintain a standard of good conduct. KSEN reserves the right to require a student to withdraw at any time if conduct and behavior jeopardizes the welfare or fulfillment of the objectives of the project. It is understood that the student's parent(s) or legal guardian(s) will assume all responsibility, either financially or otherwise, for any illness or injury which might occur during the expedition. Emergency transport, medical or hospitalization costs resulting from illness or accident during the expedition are the responsibility of the parent(s) or guardian(s) of the student receiving such care. In cases where the Project Leader, in consultation with local medical authorities, considers it necessary, a student will be sent home or hospitalized. KSEN will make every effort to ensure that ill or injured students receive proper medical attention. The parent(s), legal guardian(s), and student are aware that while taking part in this project certain exposure to risk may occur. Exposure may include but not be limited to: accident and/or sickness without readily available medical facilities, the forces of nature, travel on the ground and in the air, and others. In consideration of the right for the student to participate in this project, the parent(s) or legal guardian(s) assumes all of the risks involved and agrees to indemnify and hold the sponsors of the project harmless for any and all liability that may arise in connection with participation in the activities. I have read and fully understand and accept the conditions for participating as detailed above.

Parent or Guardian Signature___________________________________________________

Print Name of Parent or Guardian_______________________________________Date________________

Student Signature __________________________________________________________

Print Name of Student_____________________________________Date____________________

Please send application packet and deposit of $500 made payable to KSEN to:

KSEN, Suzanne Lettrick, Center for the Study of Eurasian Nomads, 1607 Walnut Street, Berkeley, CA 94709

Phone: (510) 549-3708 FAX: (510) 849-3138 E-mail:lettrick@csen.org