Please Complete: Health and Behavior Form

Health and Behavior Form

Page 1

This Document Must be Completed by a Parent/Guardian if the Participant is Under the Age of 18


At VISIONS, it is our goal to provide an impactful and successful experience for each participant. To support that goal, and to benefit the wellbeing of the participant, it is imperative that all health and behavior information is fully disclosed. A participant will not be registered in a program until this form has been submitted and reviewed by a VISIONS representative. Please note the following:
  • After submitting this form, contact VISIONS immediately in the case of changes or updates in health or behavior.
  • Living in a foreign environment may create unexpected physical and emotional stress, which may exacerbate otherwise mild conditions. Full disclosure will allow program leaders to be better prepared, and to facilitate a safe and successful experience.
  • Participants with chronic medical conditions should be prepared and equipped to manage those conditions while on the program.
  • Participants who have been treated for a psychological condition, or who are currently prescribed a psychotropic, must be medically stable (meaning changes in symptoms are not expected).     
  • VISIONS strives to be in compliance with the Americans with Disabilities Act, and we make reasonable accommodations when possible.
The parent/guardian(s) and participant are ultimately responsible for researching and understanding VISIONS, and for determining a participant’s suitability for a program. VISIONS is not a rehabilitation program and our programs are not appropriate for everyone. VISIONS recommends that you consult with a physician and/or travel doctor relative to any health or behavior concerns. This should include discussing vaccinations that may be suggested.

example: 4'10"

example: 130


Asthma/Respiratory Problems

VISIONS requires all participants with asthma or respiratory issues to bring with them the medications and associated devices (i.e.: inhaler, nebulizer, spacer, etc.) for all status levels, including: daily (green), caution (yellow), and emergency (red). We recommend bringing multiple emergency inhalers, depending on the severity of the case.


Physical Restrictions

Mental Health
Prior to acceptance, participants with a history of psychotherapy must be medically stable. VISIONS is not appropriate for applicants who have just completed a residential treatment program.

VISIONS is not a program for youth at risk, and inappropriate placement can be detrimental to the participant and to the program. Behavior issues are subject to reprimand and can lead to dismissal from the program without refund. 

Additional Information


Contacts and Insurance

First Emergency Contact

Second Emergency Contact

Medical Providers
(This section is optional)

Health Insurance

Signature and Email Verification are Required to Complete this form!

After signing this form, you will immediately receive an email asking you to verify your signed response. You need to click on the link in the email to finish this form and be able to register for your program.