Welcome to the Odyssey Wilderness Programs Online Application Form. This secure application process will collect information, grouped into five sections, that will allow our Treatment Team to determine whether your child is eligible for the Odyssey program and to make recommendations on the level of treatment.

Privacy & Security

Odyssey Wilderness Programs will not sell, trade, or share your personal information in any form.

This secure application form is verified by THAWTE, a trusted name in internet security, who verified our credentials and issued us a digital certificate. This certificate assures you that we are in compliance with Internet protection protocol. THAWTE uses Secure Sockets Layer (SSL) technology to encrypt personal customer information required to complete any transaction.

All payments are processed through Paypal, one of the most trusted and recognizable payment gateways on the Internet today.

TUITION PAYMENT AND REQUIRED DOCUMENTS

Once your child’s application has been approved, you will need to submit program tuition for the initial four-week program, along with copies of the following documents to confirm your child’s enrollment:

• Completed Admissions Interview*

• Completed OWP Enrollment Agreement

• Completed Physical Examination Form

• Birth Certificate

• Immunization Records

• Insurance Card

• Psychological Evaluation, if applicable

• Parenting Plan, if applicable

* Note: The application includes a one-time $125 application fee.

 

Person Filling Out This Form*:
Email Address*:
Relationship to student:
Preferred Course Start Date:
Expected Course Length:
Do you anticipate your child will attend a secondary placement post-Odyssey? If yes, where?

* = Required Fields

Child's Information

First Name:

MI:

Last Name:

Prefers to be Called:

Age:

DOB:

Height:

Weight:

Sex: M F

Soc Sec #:

Is He/She Adopted:

At What Age?

Hair Color:

Eye Color:

Race (Optional):

Religion:

Shirt Size: S  M  L  XL  XXL

Shoe Size:

Pants Size: Men's Women's S  M  L  XL  XXL

List Any Serious Medical Conditions:
List Current Prescription Medications:
Who Does the Child Live With?
Who has Legal Custody?

Father's Information

First Name:

MI:

Last Name:

Street:

City:

State:

Zip:

Age:

Occupation:

Work Phone:

Fax:

Call Before Faxing

Email:

Home Phone:

Cell Phone:

Mother's Information

First Name:

MI:

Last Name:

Street:

City:

State:

Zip:

Age:

Occupation:

Work Phone:

Fax:

Call Before Faxing

Email:

Home Phone:

Cell Phone:

Stepfather's Information

First Name:

MI:

Last Name:

Age:

Home Phone:

Work Phone:

Stepmother's Information

First Name:

MI:

Last Name:

Age:

Home Phone:

Work Phone:

Emergency Contact Information

Full Name (Other Than Parent):

Home Phone:

Work Phone:

Cell/Pgr:

FINANCIAL RESPONSIBILITY

Person Financially Responsible:
Employer:

How Did You Hear About Us?

Internet

Consultant:

Other:

Preferred Method of Payment for Odyssey Program Tuition:

Preferred Method of Payment for Odyssey Program Tuition: Cashier’s Check or Certified Check  Wire Transfer VISA or MasterCard 

Payment for program tuition will be due upon acceptance in the Odyssey program and is not collected as part of this application process. However, a valid credit card number must be submitted with this application to be used for the tuition payment when due (if selected as the preferred method of payment above) and for emergency expenses that may be incurred during the student's program.

Card Number:

Security Code:

Exp Date:

Name of Cardholder:

Date:

Billing Address:

City:

State:

Zip:

I hereby authorize Odyssey Wilderness Programs to charge my VISA/MasterCard for $12,905 for the four-week program tuition (unless otherwise specified), plus the $1,200 enrollment fee, after being confirmed of my son’s/daughter’s enrollment.

Medical INFORMATION

Please check yes or no to the following questions. If you check yes to questions 3,4,or 6-14, please provide brief explanations in the space provided below.

Y	N
		1. Does your child wear glasses?
		2. Does your child wear contact lenses?
		3. Is your child under the care of a Primary Care Physician? Doctor's Name: Doctor's Phone:
		4. Is your child under treatment with an orthodontist for braces or retainers? Orthodontist's Name: Orthodontist's Phone:
		5. Has your child had a dental exam in the past six months? Dentist's Name: Dentist's Phone:  Date:
		6. Does your child have asthma?
		7. Is your child allergic to anything? Please describe below.
		8. Have there been problems with your child's hearing/speech? Please describe below.
		9. Has your child ever been hospitalized or had surgery? Please describe below.
		10. Has your child had a hot or cold weather injury (i.e. frostbite, heat stroke) within the past five years? Please describe below.
		11. Does your child have a history of frequent accidents? Please describe below.
		12. Has your child ever broken a bone? Please describe below.
		13. Is your child taking any prescription medications? Please indicate name, dose, and frequency below.
		14. Has your child recently been taken off any psychotropic medications? Please describe below.
		15. Has your child had any disease or major illness? Please describe below.

 

Please use the space below to include any additional information related to the questions above.

 

Please provide the following information for each medication that your child is currently taking:

Medication:
Dose:	Time of Administration:	Frequency:
Medication:
Dose:	Time of Administration:	Frequency:
Medication:
Dose:	Time of Administration:	Frequency:

Immunization Records

NOTE: All children must have Tetanus Immunizations (within 10 years) prior to enrollment.

Y	N
		Is your child up to date on age-level immunizations? Date of last Tetanus Immunization:

Insurance Information

Insurance Co:

Street:

City:

State:

Zip:

Ins. Claims Phone #:

Policy #:

Policy Holder Name:

Policy Holder SS#:

Employer (if Group Policy):

Behavior History

Please check all that apply and provide a brief explanation for each checked item in the space provided:

	Academic Issues Additional Information:		Abortion Additional Information:
	ADHD Additional Information:		Adoption Additional Information:
	Aggressive Behavior Additional Information:		Depression Additional Information:
	Anger Management Additional Information:		Arrest History Additional Information:
	Theft Additional Information:		Conduct Disorder Additional Information:
	Current Legal Issues Additional Information:		Defensive Behaviors Additional Information:
	Alcohol Use/Abuse Additional Information:		Drug Use/Abuse Additional Information:
	Suicidal Ideation Additional Information:		Suicide Attempts Additional Information:
	Violence Additional Information:		Eating Disorder/Weight Issue/Obesity Additional Information:
	Trauma Additional Information:		Family Conflict Additional Information:
	Fire-setting Additional Information:		Grief/Loss Additional Information:
	Sexual/Gender Identity Additional Information:		Manipulation Additional Information:
	Bullying Additional Information:		Psychotic Episodes Additional Information:
	Learning Disabilities Additional Information:		Physical Abuse Additional Information:
	Running Away Additional Information:		Truancy Additional Information:
	Self-Mutilation Additional Information:		Promiscuity Additional Information:
	Sexual Abuse Additional Information:		Sexual Acting Out Additional Information:
	Pregnancy Additional Information:

 

Please check all that apply and include any related information:

	Previous Counseling: Reasons for Counseling: Therapist: Phone: Year: Therapist: Phone: Year: Therapist: Phone: Year:
	Current Counseling: Reasons for Counseling: Therapist: Phone: Year:
	Previous Psychiatric Hospitalization: Reasons for Hospitalization: Institution: Phone: Year:
	Previous Wilderness: Location: Year:
	On Probation: State: Period: Reasons for Probation:

 

Substance Abuse History

If your child has a history of substance abuse, please provide the following information:

Substance: Frequency: Length of Use: Most Recent Use:   Substance: Frequency: Length of Use: Most Recent Use:   Substance: Frequency: Length of Use: Most Recent Use:   Substance: Frequency: Length of Use: Most Recent Use:

School History

Please list each school your child has attended. Begin with the school most recently attended and provide the address, city, state and zip for the most recent school:		Grades attended:
1.
	Street: City: State: Zip:
2.
3.
4.

Family INFORMATION

Please check all that apply to immediate family members and provide brief explanations for each checked item in the space provided below.

	Are the parents married?	If yes, for how many years?
	Are the parents divorced?	If yes, for how many years?

 

	Mental Illness		Physical Abuse
	DCFS/CPS Involvement		Emotional Abuse
	Sexual Abuse		Alcohol Abuse
	Divorce		Remarriage
	Grief/Loss		Suicide
	Legal Issues		Eating Disorders
Please use the space below to include any information related to checked items above:

Sibling Information

List the child's siblings, including name, age and the school they currently attend:

	Adopted?
	Adopted?
	Adopted?
	Adopted?

After you submit this application form, you will be taken to Paypal where the application fee can be paid by using any major credit card, your paypal account or an e-check. You will be notified by email once the payment is received.

 

Thank you for applying to Odyssey Wilderness Programs.