The Center for Interim Programs - Interest Sheet and Application

Interim Interest Sheet

Congratulations on taking this first step toward your gap time!

The purpose of this Interest Sheet is to start you thinking about where you want to travel, interests you hope to explore, and skills you would like to develop. Dream big and don't limit your ideas; most gap year opportunities do not require previous experience so you just need an open mind and the willingness to apply yourself. Planning gap time is a dynamic process and your ideas will continue to evolve. We will use this Interest Sheet simply as a starting point for the initial free brainstorming session.

Please fill out the Interest Sheet below and click 'Submit'. NOTE: Fields marked with an asterisk (*) are required.

Privacy Policy: This information is confidential and for Interim's use only. It will not be distributed or sold to third parties.

*Personal Information*
Today's Date
First Name*		Last Name*
Preferred Name		Male	Female
Age	Date of Birth
Address*	City*		State*	Zip*
Home Phone	Cell Phone		Email*	Skype
Int'l Phone	What Country/Countries do you hold citizenship?
For Office Use Only - Please Leave Blank
*Education*

I am currently a	High School Student	High School Grad		College Student	College Graduate
	Mid-Career Professional	Retiree	Other
High School		Graduation Year
College		Graduation Year
Graduate Work		Graduation Year
*Parent Contact Information*

Parents' Marital Status	Married: Separated: Divorced: Other
Parent 1
First Name	Last Name	Occupation
Home Phone:	Work Phone:	Cell Phone:	Email:
Parent 2
First Name	Last Name	Occupation
Home Phone:	Work Phone:	Cell Phone:	Email:
*Emergency Contact Information*
First Name	Last Name	Relationship
Home Phone:	Work Phone:	Cell Phone:	Email:
*Medical Background*

Do you have any known allergies? If so, what are they?

Do you have any dietary restrictions or preferences? If so, what are they?

Please tell us about any physical, medical or psychological conditions for which you are currently being or have recently been treated, even if you don't feel that it would affect your participation in a program. Examples include: depressive disorders, ADD, AD/HD, diabetes, alcohol/drug addiction.

Are you currently on medication? If so, which and for what?

*Experiences and Interests*
How did you hear about Interim? Please be specific.
When would you like to begin your gap time, and how long would you like it to last?
What work and/or volunteer positions have you held?
What hobbies do you have? What do you enjoy doing in your free time?
What subjects in and out of school have you enjoyed?
What languages have you studied and for how long? Is there a language that you would like to focus on during your gap time?
Where have you traveled in the U.S. and abroad?
Have you attended organized programs outside of school or work? If so, what and where?
*Geographic Locations*

Please check all regions and specific countries that interest you.

*U.S.A.*
Northeast	Midwest	Southeast	The Rockies	Appalachia	Southwest
Alaska	Hawaii	Northwest	California
*Canada*
*Europe*
Austria	England/UK	France	Germany	Greece	Ireland
Italy	Spain	Switzerland	Eastern EU	Scandinavia	Netherlands
*Central America*
Caribbean	Belize	Costa Rica	Guatemala	Mexico	Nicaragua
*South America*
Argentina	Bolivia	Brazil	Chile	Ecuador	Peru
*North Africa*
Morocco	Egypt
*West Africa*
Ghana	Cameroon	Senegal
*East Africa*
Kenya	Tanzania	Uganda
*Southern Africa*
Madagascar	Namibia	Botswana	South Africa
*Asia*
China	India	Japan	Mongolia	Nepal	Russia
Thailand	Vietnam
*Oceania*
Australia	New Zealand	Fiji	Micronesia	Indonesia
*Middle East*
Israel	Jordan	Turkey
*Other Geographic Locations*
*Opportunities and Activities*

Please check all boxes that interest you, regardless of your experience, and/or add your own!

*Lifestyle*
Indoor	Outdoor	Urban	Rural	Homestay	Independent
Peer Group
*Program Type*
Academic	Experiential	Skill Based	Internship	Volunteer	Work Exchange
Cultural Immersion
*Animals*
Wild	Domestic	Elephants	Horses	Big Cats	Primates
Penguins	Sea Turtles	Dolphins	Whales	Sled Dogs	Birds
*Arts*
Art History	Blacksmith	Ceramics	Cooking	Drawing	Glasswork
Graphic Design	Jewelry	Metal	Painting	Photography	Sculpture
Textiles	Woodcraft	Writing
*Building*
Architecture	Construction	Natural Bldg	Restoration	Boats
*Environmental Study*
Field Research	Forestry	Marine Biology
*Languages*
Spanish	French	Chinese	German	Portuguese	Italian
Arabic
*Other Languages*
*Media*
Computers	Film	Radio	Recording	Video/TV
*Music*
Drums	Guitar	Horns	Piano	Voice	Guitar Making
*Performance*
Dance	Theater	Production
*Professional*
Business	Event Plans	Fashion	Hotel Mgmt	Journalism	Medical
Museum	Politics	Restaurant	Technology	Veterinary	Zoo/Aquarium

*Outdoor Skills*
Backpacking	Canoeing	Kayaking	Rock Climbing	Sailing	SCUBA
Skiing	Snow Boarding	Surfing	Survival	Wilderness Medicine	Outdoor Leadership
*Spiritual Disciplines*
Buddhism	Healing Arts	Martial Arts	Meditation	Native American	Yoga

*Volunteering*
Animals	Archaeology	Children	Environmental Conservation	Elder Care	Healthcare
Organic Farming	Anthropology	Ranching	Teaching	Trail Building	Special Needs
Sports	Wildlife Conservation	Human Rights
*Other Opportunities and Activities*

*Your Ideal Gap Time*
If you could do anything, what does your ideal gap time look like?
*Send A Photo!*

After you submit this Interest Sheet please send us a recent photo by email, or send a URL where we can find your picture.

Interim Interest Sheet

Personal Information

Education

Parent Contact Information

Emergency Contact Information

Medical Background

Experiences and Interests

Geographic Locations

Opportunities and Activities

Your Ideal Gap Time

Send A Photo!