Please include your full name (first, middle, last and suffix, if applicable) exactly as it appears on your passport or government-issued photo ID.
Please indicate your sex as it appears on your current passport or government-issued ID.
This is required in case your trip organizers need to find you when the ground transportation is departing from campus.
Emergency Contact Information
Carbon Footprint Calculation
As a continuation of Williams' "Confronting Climate Change" initiative, we are asking all Break Out Trip participants to calculate their individual carbon footprint, and for each trip to consider possibilities for reducing or offsetting this footprint.
Please check all that apply.
Please indicate the round-trip mileage for your primary mode of transportation.
to calculate. Click "Individual Calculator," then choose your primary
vehicle type, destination, etc. Your emissions will be calculated in "lbs of CO2e") on the bottom right hand side.
If you have any particular health issues or concerns of which you feel we should be aware, please describe them here.
Please list any medications you take regularly of which you would like us to be aware, particularly any prescriptions which may need to be replaced if lost while traveling.
Please list any serious allergies which may require use of an EpiPen or other emergency attention.
By clicking "Submit," you certify that the information you have provided on this form is accurate, true and complete to the best of your knowledge.