VISIONS Service Adventures: Pre-Program COVID Form
STUDENT/STAFF Information
First Name
Last Name
Phone
Email
PARENT/GUARDIAN Information
First Name
Last Name
Phone
Email
VISIONS Program
Which VISIONS program you are attending?
Please select...
British Virgin Islands
Dominican Republic
Montana Blackfeet 1
Montana Blackfeet 2
Montana Blackfeet Middle School
Montana Farm and Ranch 1
Montana Farm and Ranch 2
Montana Farm and Ranch 3
GENERAL HEALTH
Over the past ten days, have you, at minimum, adhered to your government, state or local requirements and recommendations regarding non-essential travel, social distancing, mask wearing, and group sizes, etc.?
Please select...
YES
NO
Have you tested positive for Covid-19 within the last 90 days?
Please select...
YES
NO
If you answered yes, please explain below.
(*NOTE- if you have tested positive in the last 90 days and are traveling to the D.R. or BVI, please call VISIONS office immediately at 406.551.4423)
COVID-19 VACCINE
Have you received a COVID-19 vaccination?
Please select...
FULLY VACCINATED
NON-VACCINATED
RECEIVED ONLY FIRST DOSE
Date of Initial Vaccination and Type:
If you have received a Covid-19 Vaccine, please upload a copy of your CDC card:
COVID-19 TESTING
Have you received your Negative Pre-Program Covid-19 Test? (*
Note that this must be a Nasopharyngeal RT-PCR test taken within five days of traveling to the program).
Please upload negative test results here:
reCAPTCHA helps prevent automated form spam.
The submit button will be disabled until you complete the CAPTCHA.
Contact Information