Utah Expedition Application Utah Expedition Application - Week 4: June 10-14 "*" indicates required fields Applicant InformationName* First Last Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AgeAddress Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary PhoneAlternate PhoneEmail* Preferred Method of CommunicationSelect...PhoneEmailMailMinor Applicants (Ages 15-17)Minor applicants must be 15 years old by the first day of the field expedition session he or she will attend. Minors must be accompanied at all times by a parent or guardian who must apply for and be independently selected for participation and fully engage in field work. Each applicant must submit a separate application.Name of Minor Applicant First Last Name of Accompanying Parent/Guardian First Last Consent*We have read and understand that minor applicants must be accompanied by a parent or guardian at all times. This parent or guardian must also apply for and be selected to participate in the Burpee Museum Expedition Program. Parents or Guardians accompanying minor participants are expected to fully engage in field work. I understand.Emergency ContactIf your Emergency Contact will also be an Expedition Participant, please list a secondary contact below.Contact InfoNameRelationshipPhone Add RemoveBackground Information1. Have you been a Burpee Expedition Participant before?Select...YesNoIf Yes, in what year(s) and at what location(s)?2. Are you a teacher, college instructor or professor?Select...YesNoIf Yes, what grade level, institution, and subject(s) do you teach?3. Are you a student?Select...YesNoIf Yes, what is your year of study and major/focus? At what institution?4. Have you previously collected fossils or participated in similar activities?Select...YesNoIf Yes, please list the activity, time period, general location, and sponsoring institution or group.5. In the past five years, have you camped out, attended outdoor camp, or participated in any scientific field expeditions?Select...YesNoIf Yes, please list the activity, time period, general location, and sponsoring institution or group.6. Have you ever used power tools?Select...YesNoIf Yes, please list the power tools and circumstances (e.g. work, home, school, hobby, etc.)TransportationGetting to Hanksville, Utah: Participants are responsible for their own transportation and travel costs to Hanksville, Utah from their point of origin, and from Hanksville, Utah to their destination after participation in the Burpee Museum Expedition Program. Participants are responsible for their lodging while en route to and from Hanksville, Utah. The closest major airport to Hanksville, Utah is in Grand Junction, Colorado. Rental cars are generally available in Grand Junction. Pick up and drop off is available at the Grand Junction Regional Airport for a roundtrip fee of $150/participant, however, flights must be scheduled as follows: Expedition airport shuttle will leave Grand Junction Regional Airport (GJT) at 3:00 pm MDT on the Sunday prior to the session start date. Participant’s flight must arrive at GJT before 2:30 pm MDT on Sunday. Expedition airport shuttle will return to GJT by 12:00 pm MDT on the Saturday following the expedition. Participant’s departing flight must be scheduled to leave GJT after 1:00pm MDT on Saturday. Expedition Staff will make one trip to GJT to pick up Participants on Sundays, and one trip to drop off Participants on Saturdays. Expedition Staff cannot provide transportation to or from any airport or transportation location other than the Grand Junction Regional Airport on the days and times listed above. Burpee Museum cannot make accommodations for flights that are delayed, canceled, rescheduled, or missed. Transportation fees cannot be refunded. TransportationExpedition Field Site Transportation: Burpee Museum Expedition Staff will provide transportation for Participants to and from a designated location in Hanksville, Utah, and the Hanksville-Burpee Dinosaur Quarry once each day. Vehicles will depart Hanksville at approximately 8:00 am and return from the Hanksville Burpee Dinosaur Quarry at approximately 6:00 pm each day. Participants can expect to be in the quarry from approximately 9:00 am to 5:00 pm daily; the drive to/from the quarry is approximately 45 minutes each way. For minors 8-14 years old, Guardians are required to provide transportation to and from the dig site. Consent*I understand that I am responsible for my transportation to and from Hanksville, Utah before and after my expedition session and that only transportation to and from the Hanksville-Burpee Dinosaur Quarry will be provided to me by Burpee Museum during my expedition session. I understand.Lodging and Food Lodging and food are not included in the Participant fees for the Jurassic Journey Field Expedition to Hanksville, Utah. Each Participant is responsible for arranging their own lodging prior to arriving in Hanksville, Utah. Participants are responsible for their own meals and beverages during their expedition session in Hanksville, Utah. Hanksville, Utah is a small, rural town with limited services. Participants with food allergies or who have specific dietary needs should be prepared to meet their own needs. Burpee Museum can NOT meet personal food preparation requirements or dietary needs of any Participant. Additionally, Burpee Museum can NOT guarantee an allergen-free environment for any Participant who may have food allergies. Burpee Museum does not provide meal service in the field. Participants should bring a sack lunch to the quarry each day. Participants are required to bring at least two personal liter containers of water with them to the quarry each day. Communal water jugs are provided as an extra water resource. Consent*I understand that I am responsible for my lodging, food, and beverage during the Jurassic Journey Expedition in Hanksville, Utah. Additionally, I understand that if I must adhere to a specific diet for any reason I must be prepared to meet my own dietary needs while on the expedition in Hanksville, Utah. I understand.Field Conditions and Participant RequirementsBy requesting consideration for selection to be a Participant on any of the fossil field collecting expeditions led by the Burpee Museum of Natural History (“Burpee Museum”), you understand and agree with the following statements and will abide by all requirements: The Burpee Museum is a federal repository for fossils and conducts scientific field expeditions for the purpose of fossil collection and research in accordance with laws regulations, and rules set forth by the Bureau of Land Management. All Expedition Participants are required to follow all applicable legal requirements. The Burpee Museum Expeditions are: held in desolate and isolated areas of Utah that can have unpredictable and extreme weather conditions. This can include large daily temperature fluctuations, high and low temperatures, violent winds, and storms. Such weather may cause field activities to be canceled or shortened. Weather may also be life-threatening and cause in-field stranding, unpassable roads, and other dangerous conditions; in areas with plant, animal, and insect life that can cause injury or death, e.g., poisonous snakes, scorpions, spiders, fire ants, cacti, and cougars. Participants can potentially suffer from things such as sunburn, windburn, heat stroke, venomous and non-poisonous bites, cuts, bruises, abrasions, sprains, broken bones, dehydration, and other injuries and circumstances up to and including loss of life; located in a territory often very distant from medical care clinics and hospitals. Due to field conditions, geography, or particular incidents, Participants may not be able to receive professional medical support or care in a timely fashion; situated in a variety of field site settings that require hard physical labor, long work hours, close working quarters with fellow Participants, and walking on uneven, elevated, slippery, and rough ground. Additionally, expedition participants may be exposed to prolonged sunlight, loud continual noise, and dust from wind and power tools, and other weather-related or manmade hazards. All Participants are assigned to a field crew which must act in concert with other crews in order to achieve the scientific purposes of the expedition. Burpee Museum cannot make accommodations in the field to meet the needs of individual Participants, e.g., shortened work days, and special dietary requirements. The success of the respective Burpee Museum field expeditions is dependent on the full participation of all expedition Participants in order to meet the expedition's Scientific and field collection goals. All expedition Participants must conduct themselves in a manner compatible with safe and legal collection practices and engage in respectful camp practices and interactions with other expedition Participants. Suppose an expedition Participant is unable to do so. In that case, his or her Participant status may be revoked at the discretion of Burpee Museum’s Director of Collections and exhibits, Science Programs Manager, or Executive Director. In the case of a Utah expedition Participant, this means that the person may no longer work on-site at the Hanksville Burpee Quarry. If a Participant has his or her status revoked by Burpee Museum, no refunds of fees paid will be provided. In the case of a Minor whose Participant status is revoked, the Parent or Guardian of that Minor will also have his or her Participant status revoked. Burpee Museum is not responsible for any expense or circumstance that arises from a former Participant after his or her status is revoked. Any subsequent transportation, lodging, food, or other expenses that incur to a person who has had his or her Participant status revoked is the responsibility of that person or his or her Parent/Guardian. Consent*I understand that I will be exposed to potentially hazardous or extreme working conditions if I am selected to participate in an expedition. I also understand that I am expected to fully participate in the activities of the expedition, as well as abide by any and all state and federal laws that govern the expedition. Further, I understand that I will be working, traveling, and lodging in close quarters with other Participants and that my Participant status may be revoked at any time if I am unable to do so in an appropriate manner. If my Participant status is revoked I will not be eligible for any refund, and will not be able to work at the Hanksville-Burpee Dinosaur Quarry. I understand.Health History, Insurance, and CarePlease complete the following:AllergiesAllergiesSelect...Applicant has no known allergiesApplicant has known allergies and is allergic to:Allergic to: Food Medicine Environment (insect stings, hay fever, etc.) Other DescribePlease describe what the Applicant is allergic to and what the known reactions are.If the Applicant has known allergies, what is the course of action for treatment?Select...OTC AntihistaminesRx AntihistaminesEPI PenOtherDescribePlease list the name and dosage of any and all allergy medications. Participants with life threatening allergies are required to have allergy medication with them at all times.Diet, NutritionDiet, NutritionSelect...Applicant eats a diet with no special restrictions.Applicant requires a diet with special restrictions.DescribePlease describe any special restrictions.General Health History Check Yes or No for each statement. Explain Yes answers. Has/Does the Applicant:1. Ever been hospitalized? Yes No 2. Ever had surgery? Yes No 3. Ever had a broken bone? Yes No 4. Ever had a concussion or other head injury? Yes No 5. Have a recurrent/chronic illness? Yes No 6. Had a recent infectious disease? Yes No 7. Had a recent injury? Yes No 8. Have/Had asthma/wheezing/shortness of breath? Yes No 9. Have diabetes? Yes No 10. Have/Had seizures? Yes No 11. Have/Had headaches or migraines? Yes No 12. Wear glasses/contacts/protective eyewear? Yes No 13. Have glaucoma or other vision problems? Yes No 14. Had dizziness or fainting? Yes No 15. Passed out/had chest pain during exercise? Yes No 16. Have a Pacemaker or other regulatory device? Yes No 17. Require dialysis? Yes No 18. Ever had back/joint problems? Yes No 19. Have/Had arthritis or rheumatoid arthritis? Yes No 20. Smoke? Yes No 21. Have orthodontic braces/dental implants/dental hardware? Yes No 22. Have a blood-borne disease? Yes No 23. If female, do you plan to be pregnant during the expedition? Yes No 24. Have/Had cancer? Yes No 25. Traveled outside of the United States in the last 12 months? Yes No 26. Have/Had an eating disorder? Yes No 27. Had a Tetanus Booster in the last 2 years? Yes No 28. Have any physical limitations? Yes No 29. Use a prosthetic? Yes No 30. Have a current Do Not Resuscitate Order? Yes No 31. Have had a stroke? Yes No 32. Have had a Heat Stroke? Yes No ExplainMental, Emotional, and Social Health Check Yes or No for each statement. Explain Yes answers. Has the Applicant:1. Ever been treated for attention deficit disorder (ADD) or attention-deficit/hyperactivity disorder (AD/HD)? Yes No 2. Ever been treated for Autism or an Autism Spectrum disorder? Yes No 3. During the past 12 months, see a professional to address mental or emotional health concerns. Yes No ExplainMedicationMedicationSelect...Applicant will not take any daily medications while on expedition.Applicant will take the following daily medication(s) while on expedition.MedicationMedication NameReasonDosage/DayForm (Pill, Liquid, Injection, etc.) Add RemoveOther Pertinent Information Please provide any additional information about the Applicant’s health that you think is important or that may affect the Applicant’s ability to fully participate in the Expedition program. Attach additional information if needed. Additional InformationFileMax. file size: 768 MB.RestrictionsRestrictionsSelect...I have reviewed the Expedition Application, including the Field Conditions and Participant Requirements, and am fully able to participate with no restrictions.I have reviewed the Expedition Application, including the Field Conditions and Participant Requirements, and am able to participate with the following restrictions or adaptations described belowRestrictions and AdaptationsBased on your personal statement of your health and health history, Burpee Museum reserves the right to request a statement of fitness for expedition participation from your attending physician.Health-Care ProvidersHealth-CareName of Applicant’s Primary Doctor(s)Phone Add RemoveHealth-CareName of Applicant’s Dentist(s)Phone Add RemoveMedical Insurance InformationThis Applicant is covered by medical/hospital insurance. Yes No If Yes: Include a copy of your insurance card; copy both sides of the card so that the information is legible. Drop files here or Select files Max. file size: 768 MB. Insurance CompanyPolicy/Group NumberSubscriberInsurance Company PhoneAuthorization for Health Care*This health history is correct and accurately reflects the health status of the Applicant to whom it pertains. The Applicant has indicated that they are able to participate in the Burpee Museum Field Expedition fully, unless otherwise indicated or as advised by a physician or, in the case of a minor Participant, a parent/guardian. The Applicant (or Applicant’s parent/guardian) gives permission for any Burpee Museum Staff Member or Agent to seek treatment from a health care provider who can order x-rays, routine tests, and treatment related to the health of the Applicant in emergency situations. If the Applicant is unable to, and the Emergency Contact(s) cannot be reached, the Applicant (or Applicant’s parent/guardian) gives permission for health care providers to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for the Applicant. The Applicant (or Applicant’s parent/guardian) understands that the information on this form will be shared with Expedition Staff on a “need to know” basis. The Applicant (or Applicant’s parent/guardian) gives permission for this form to be photocopied. The Applicant (or Applicant’s parent/guardian) understands that they are fully and solely responsible for all health, medical, and/or dental care costs incurred directly or indirectly from expedition participation and that Burpee Museum of Natural History, its staff, and agents, have no responsibility for any health, medical, and/or dental care costs that arise out of treatment or care received by the Applicant. The Applicant (or Applicant’s parent/guardian) waives their right to sue Burpee Museum of Natural History, its staff, or agents for any such costs. I understand.Sessions and RatesThe Jurassic Journey Expedition to Hanksville, Utah has a 3-day attendance minimum. Applicants can sign up for any three or four days within a session, or sign up for the entire 5-day session. Saturdays and Sundays are not field days and do not count towards the attendance minimum.Daily Rates (Minimum of 3 Days) General: $300/Day Returning Participants/Students/Members: $275/day Weekly Rates General: $1500/5 Days Returning Participants/Students/Members: $1300/5 Days Application Notes All applications must include a $400/Applicant deposit in order for the application to be reviewed. This deposit is non-refundable after April 15. The applicant will be notified by Burpee Museum, in writing or via email, of his or her selection to be a Burpee Expedition Participant. Once selected for participation an Applicant’s deposit is non-refundable. If Burpee Museum elects to cancel a session due to non-interest, the applicant will receive a full refund. An Applicant who is not selected to be an Expedition Participant will have their deposit refunded to them within 30 days of selection notification. Applications must be received and completed by April 30th to be considered for the Jurassic Journey Expedition to Hanksville, Utah. Payment must be made in full for the Jurassic Journey Expedition to Hanksville, Utah by April 30. Check - Make checks payable to Burpee Museum. Include "Exp. Deposit" in Memo. Questions may be directed to josh.mathews@burpee.org or burpee@burpee.org or calling Visitor Services 815-965-3433. CheckCheck #DL #Down Payment Due: Quantity* Price: $400.00 Quantity Remaining amount will be collected before expedition.Total Credit CardPhoneThis field is for validation purposes and should be left unchanged.
