Interim Programs - Mid-Career and Career Break Application
Date
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 Age
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 Birthdate 
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Name (First & Last)
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 Nickname
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 Male Female 
Address___________________________________________________________________________________
City
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 State 
___________________________
 Zip 
___________________________
 
E-mail  ________________________________________________
 
High School ___________________________
 
Graduation Year ___________________________
 
College     ___________________________
 
Graduation Year ___________________________
 
Post Graduate Work  ___________________________
 
Graduation Year ___________________________
 
Relative First Name ___________________________  Relative Last Name___________________________ Relative Phone___________
 
Other Contact First ___________________________  Other Contact Last___________________________ Other COntact Phone___________
 
Your Occupation __________________________________________________  Business Information_____________________________________
       

How did you hear about Interim?
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When would you like to start?
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What work and/or volunteer positions have you held?
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What other programs have you already attended?
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Where have you traveled in the U.S. and abroad?
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What languages have you studied and for how long?
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Do you have any physical, psychological or medical conditions that might affect your participation?
Are you currently taking any medications?
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Check those categories below that help to define your interests.

Geographic Location:
Africa Japan Germany Oceania Costa Rica Chile
Ghana Nepal Ireland Australia Guatemala Canada
Tanzania Tibet Greece New Zealand Mexico United States
South Africa Turkey Italy Fiji South America Hawaii
Asia Europe Spain Micronesia Brazil Alaska
China England Russia Central America Bolivia Middle East
India France Eastern Europe Caribbean Ecuador Israel
Other          

Areas of Interest:

Indoor Outdoor Urban Rural Academic Non-academic

Agriculture Construction Horses Outdoor Edu. Social Service
Animals Cooking Hotel Mgmt. Painting Spiritual
Anthropology Cultural Study Jewelry/Metal Photography Sports
Archaeology Dance Journalism Politics Teaching
Architecture Design/Graphics Kids Radio Theater
Art & Crafts Drawing Languages Ranching Wilderness
Blacksmithing Environment Native American Recording Arts Woodcraft
Business Fashion Marine Biology Sailing Writing
Canoe/Kayak Field Research Marine Mammals School Internship Video/T.V.
Ceramics Film Medical SCUBA Yoga/Meditation
Computers Forestry Museum Sculpture Zoo/Aquarium
Conservation Glasswork Music Skiing Other

If you could wave a magic wand, what would you do?
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Please send us a recent photo by mail, or send a URL where we can find your picture.