Interest Sheet

This Interest Sheet is to help you consider possible places to travel, interests to explore, and skills to develop on your gap year. We use it simply as a starting point for the initial free 90-minute brainstorming session. NOTE: Fields marked with asterisks are required. This information is confidential and for Interim's use only. It will not be distributed or sold to third parties.

Please fill out the form below and click the "SUBMIT" button.

Personal Information

Title
First Name*
Last Name*
Preferred Name
Sex at Birth*
Additional Gender Information
Age*
Birthdate*
Interest Sheet Done
Street*
City*
State
Zip Code*
Country*
Email*
Main Phone*
Skype ID
In what countries do you hold citizenship?

Education

I am currently a -
Name of High School
High School Graduation Year
Name of College
College Graduation Year
Graduate Studies Information

Parent Contact Information

This section to be completed by applicants who are 21 and younger.
Parents' Marital Status
Parent 1 First Name
Parent 1 Last Name
Parent 1 Occupation
Parent 1 Cell Phone
Parent 1 Email
Parent 2 First Name
Parent 2 Last Name
Parent 2 Occupation
Parent 2 Cell Phone
Parent 2 Email
Brothers and Sisters
Sibling Names & Ages

Medical Background

In order for us to make referrals that are best suited to you, we ask that you answer each of the questions below. This information is kept confidential.
Do you have any known allergies? If so, what are they?
Any dietary restrictions or preferences?
Please tell us about any physical, medical or psychological conditions for which you are currently being, or have recently been, treated. Examples include: anxiety, depression, ADD, diabetes, alcohol/drug abuse and/or eating disorders.
Are you currently on medication? If so, which and for what?
Have you been hospitalized in the past 3 years? If so, for what?

Experiences & Interests

How did you hear about us?
Please add referral names here.
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 travelled 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.
To make more than one selection: On a PC hold CTRL and left-click, on a Mac holding the Command key (the apple key) and clicking should do it.
North America (USA & Canada)
Europe
Central America
South America
North Africa
West Africa
East Africa
Southern Africa
Asia
Oceania
Middle East
Other Geographic Locations

Opportunities and Activities

Please check all opportunities and activities that interest you, regardless of your experience.
Lifestyle
Program Type
Animals
Arts
Building
Environmental Study
Media
Music
Performance
Professional
Outdoor Skills
Spiritual Disciplines
Languages
Enter Other Languages Here
Volunteering
Other Opportunities and Activities
If this was your chance to do anything you have ever dreamed of, what would it be?
Captcha: Please type what you see
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After you submit this Interest Sheet, please send a recent photo, or URL link to your photo, to us at: info@interimprograms.com

Ready to get started?

Fill out our Interest Sheet for a free 90-minute consultation or Contact Us with general inquiries.
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