INTERIM Programs - Application

*Why Interim* Programs?**
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*Contact Interim* Programs**

Application

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

If you prefer, click right on the following link to download and save the application which you can fill out in your word processor (e.g., MS WORD)and save. Then print and mail or FAX the completed form to us, or email the completed and saved file to info@interimprograms.com. You may also use your PC's printer from your web browser to print the text version of the application which you can fill out by hand and return to one of our offices by FAX or mail.

Date	Age	Birthdate
First Name*	Last Name*	Male	Female
Nickname	Address*
City*	State*	Zip*

Home Phone*		Email
High School		Graduation Year
College		Graduation Year
Mother's First Name		Mother's Last Name
Father's First Name		Father's Last Name
Father's Occupation		Mother's Occupation
Parents' Marital Status	Married:	Separated:	Divorced:	Other:
Mother's Phone Contacts	Home	Work	Cell
Father's Phone Contacts	Home	Work	Cell
Father's Email		Mother's Email

How did you hear about Interim?

When would you like to start?

What work and/or volunteer positions have you held?

What other programs have you already attended?

Where have you traveled in the U.S. and abroad?

What languages have you studied and for how long?

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.

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 with your Interim time?

Please send us a recent photo by mail, or send a URL where we can find your picture.