Costa Rica Questionnaire Please enable JavaScript in your browser to complete this form. - Step 1 of 8Please fill out this form as completely as you can. The more information we have, the better prepared we all are for a successful experience. Please submit by October 18th. Thank you. Full Name of Student *FirstMiddleLastBirthdate *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age *Country of Citizenship *Name of Parent(s)/Guardian(s) *Who is filling out this form: *FirstLastYour Email Address *Do all guardians/parents consent to this trip? *YesNoOtherNextHOME LIFEWith whom does your child live?In what organized activities does your child participate outside of school (sports, plays, dance, lessons, etc)?What does your child usually do during their spare time?NextEATING HABITSHow many meals does your child eat per day?How much does your child generally eat (half of the portion served, seconds, etc)? How often do you or your family cook at home? How often do you eat out? What are your child’s favorite foods?What foods does your child not eat and why?NextMEDICATIONSWhat types of medications does your child take? How often? What are they for?Does your child have any physical conditions that have to be monitored / medicated / known by the adults around them?NextSLEEP HABITSWhat time does your child generally wake up and go to sleep? How many hours of sleep do they need to feel fully rested?Is your child able to sleep through the night? If not, how often do they wake up? Why do you think they wake up in the middle of the night?Does your child share a room? If yes, with whom? What is that like? NextTRAVELHas your child ever slept away from home? Where were they staying and with whom (friends / relatives / camp, etc)? For how long?Has your child ever stayed with people who they don’t know? When, with whom, and for how long?Has your child traveled outside of NM before? Where? With whom did they travel? Has your child traveled outside of the USA before? Where? With whom did they travel?In the last two years has your child experienced homesickness before? What was that like? What helped them feel better?Has your child flown on an airplane before? What do they think / feel about flying? Does your child experience motion sickness? What is that like? When do you experience it?How would you rate how often your child experiences depression (persistent feeling of sadness and/or anger and loss of interest in activities)? Selected Value: 1 On a scale from 1-10 (from rarely to all the time)What does that look like for them?How often does your child experience anxiety (excessive amounts of fear, nervousness, worry, or dread)? Selected Value: 0 On a scale from 1-10 (from rarely to all the time)What does that look like for them? What kind of thoughts or experiences brings this on?Has your child ever had a panic attack? YesNoWhen was the last time they had one? How often do they have them (once a year, once a month, once a week, once a day, etc)?Do they have any specific fears that can cause anxiety? (ex. Heights, bugs, water, etc) NextPHYSICAL STRENGTHHow would you describe your child’s physical strength?Does your child have any major physical injuries that still cause issues or discomfort? (sprains, broken bones, dental issues, etc.)How often does your child exercise, walk, or hike? How many minutes at a time? Does your child play any sports? If so, which ones and how often? Is your child able to swim? YesNoHas your child ever swum in the ocean before?NextOTHERIs there any other information that would be helpful for the adults on the trip to know?What are your hopes for your child on this trip? What do you think will be a challenge for them?Submit
