Health and Special Needs

We request this information in order to best prepare your program for you and discuss any concerns you may have regarding living abroad and being successful on your program. While not required that you respond, it is strongly recommended. Your answers do not impact your application status, but your answers will allow us to check into accommodation possibilities, as accommodations available in other countries can be different than what you may be used to in the USA. For more information, please see our policies on The Learning Abroad Co. website.

Program Code*

Please check one of the boxes below and complete the form appropriately.

I willingly choose to disclose the following information to The Learning Abroad Co., and I authorizethe information to be shared with The Learning Abroad Co. staff and/or third party vendors whoprovide services for my program only on a need-to-know basis.I do not have any special needs or health concerns as listed below.I willingly choose not to disclose any information regarding my needs. I understand that The Learning Abroad Co. may not be able to assist me with any concerns listed below if I choose not to disclose the information at this time.

Do you have any dietary restrictions?*

YesNo

What foods are you not able to eat?*

Do you have any disabilities and/or do you receive any accommodations at your home institution?*

Yes, please explainNo

If yes, please explain:*

Are you currently taking any medications?*

Yes, please explainNo

If yes, please list the medication and dosage below. Prescription*

Over the Counter

Do you have any on-going health conditions that you feel The Learning Abroad Co. should be aware of?*

Yes, please explainNo

If yes, Please explain:*

In the past two years, have you been treated or met with a counselor for any mental health conditions?*

Yes, please explainNo

If yes, Please explain:*

Do you consider yourself to be in overall good health?*

YesNo, please explain

If no, please explain*

Would you like an The Learning Abroad Co. staff member to speak with you on the phone to discuss the above health concerns or any other concerns in order to learn about resources that may be avail-able on-site to assist you in having a successful program?*

YesNo

If you checked ‘yes’ to the question above, The Learning Abroad Co. will schedule a phone call with you at your convenience.

Full Name*

Email*

example@example.com

Signature*

Date*

Date