Coastal Studies Semester Application
NOTE: YOU WILL NEED HEALTH INSURANCE INFORMATION TO COMPLETE THIS APPLICATION. THIS INCLUDES:
-Subscriber's name
-Insurance company name
-Group number
-Policy number

Complete this Application AND the following 3 documents in order to be considered into the Coastal Studies Program. Return the 3 documents to Catherine Gaudlip either via email (gaudlip@hood.edu) or in-person at Hodson Office 308F.
-Health Medical Report
-Agreement & General Release Waiver
-Photo Consent Form

Questions? Contact Catherine Gaudlip.
DUE MARCH 31, 2025.

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Email *
First and Last Name *
Home Address *
Birth Date *
MM
/
DD
/
YYYY
Major and Minor (if applicable) *
Current Status *
Are you a Hood student? Yes or No. If no, then please specify which school you attend. *
Phone Number *
Email *
Why do you want to join the Coastal Studies Semester? *
Which option best fits your interest in pursuing the CSS? *
EMERGENCY CONTACT INFO
Please fill out your emergency contact information below.
First and Last Name of Emergency Contact #1 *
Home Address of Emergency Contact #1 *
Phone Number of Emergency Contact #1 *
Email Address of Emergency Contact #1 *
First and Last Name of Emergency Contact #2 *
Home Address of Emergency Contact #2 *
Phone Number of Emergency Contact #2 *
Email Address of Emergency Contact #2 *
INSURANCE INFO
Complete the health insurance information needed below.
Subscriber's First, Middle, and Last Name *
If insurance is provided through the subscriber's employer, list the Employer Name:
(If not, put NA)
 *
If insurance is provided through the subscriber's employer, list the Employer Address:
(If not, put NA)
 *
Relationship of Subscriber to Student. *
Name of Insurance Company *
Policy Number *
Group Number *
Insurance Company Mailing Address *
SUBMITTING THIS APPLICATION DOES NOT MEAN YOUR PACKAGE IS COMPLETE. OTHER DOCUMENTS NEEDED ARE:
  1. Photo Consent Form
  2. Health Medical Report Form
  3. Agreement and General Release Form
A copy of your responses will be emailed to the address you provided.
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