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.

To select (or unselect) your possible Gap Year choices in a multiple choice drop-down box below, in Windows hold down the CTRL key, in MAC hold down the Command key, then click your choices.

Salutation	-None- Mr. Mrs. Ms. Dr. Prof.
First Name*
Last Name*
Preferred Name
Sex at Birth*	-None- Male Female
Additional Gender Information
Age*
Birthdate*
Interest Sheet Done	-None- No Yes
Street*
City*
StateDropDown	-None- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code*
Country*
Email*
Mobile*
Home Phone
Skype ID
In what Countries do you hold citizenship?
I am currently a -	-None- None High School Student High School Graduate College Student College Graduate Mid-career Professional Retiree
Name of High School
High School Graduation Year
Name of College
College Graduation Year
Graduate Studies
Parents' Marital Status	-None- Married Separated Divorced Other
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 or Sisters	-None- Yes No
Sibling Names & Ages
Do you have any known allergies? If so, name them
Tell us of any dietary restrictions or preferences
Tell us of any physical, medical or other issues
Are you on medication? If so, which and for what?
Have you been hospitalized in the past 3 years?
How did you hear about us?	-None- An Interim Client Family Book Directory College Office Education Consultant Family Member Gap Fair High School Counselor Internet LEAPNow News Article Other Psychiatrist Psychologist School Presentation Word-of-Mouth
If 'Other' please be specific
When would you like to begin & for how long?
What work and/or volunteer positions have you had?
What hobbies do you have? What do you enjoy?
What subjects in & out of school have you enjoyed?
What languages have you studied and for how long?
Where have you travelled in the U.S. and abroad?
What organized programs outside of school or work?
In the Multiple Selection Boxes Below Select Those that Might Interest You on Your Gap Year
North America (USA & Canada)	Alaska Appalachia Canada Hawaii Midwest Northeast Northwest Southeast Southwest The Rockies
Europe	Austria Eastern EU England/UK France Germany Greece Ireland Italy ScandinaviaNetherlands Spain Switzerland
Central America	Belize Caribbean Costa Rica Guatemala Mexico Nicaragua
South America	Argentina Bolivia Brazil Chile Ecuador Peru
North Africa	Egypt Morocco
West Africa	Cameroon Ghana Senegal
East Africa	Kenya Tanzania Uganda
Southern Africa	Botswana Madagascar Namibia South Africa
Asia	China India Japan Nepal Thailand Vietnam
Oceania	Australia Fiji Indonesia Micronesia New Zealand
Middle East	Israel Jordan Turkey
Other Geographic Locations
Lifestyle	Homestay Independent Indoor Outdoor Peer Group Rural Urban
Program Type	Academic Cultural Immersion Experiential Internship Skill Based Volunteer Work Exchange
Animals	Big Cats Birds Dolphins Domestic Elephants Horses Penguins Primates Sea Turtles Sled Dogs Whales Wild
Arts	Art History Blacksmith Ceramics Cooking Drawing Glasswork Graphic Design Jewelry Metal Painting Photography Sculpture Textiles Woodcraft Writing
Building	Architecture Boats Construction Natural Bldg Restoration
Environmental Study	Field Research Forestry Marine Biology
Media	Computers Film Radio Recording Video/TV
Music	Drums Guitar Guitar Making Horns Piano Voice
Performance	Comedy Dance Production Theater
Professional	Business Event Plans Fashion Hotel Mgmt Journalism Medical Museum Politics Restaurant Technology Veterinary Zoo/Aquarium
Outdoor Skills	Backpacking Canoeing Kayaking Outdoor Leadership Rock Climbing Sailing SCUBA Skiing Snow Boarding Surfing Survival Wilderness Medicine
Spiritual Disciplines	Buddhism Faith-based Service Work Healing Arts Martial Arts Native American Yoga/Meditation
Languages	Arabic French German Italian Other Portuguese Spanish
Enter Other Languages Here
Volunteering	Animals Anthropology Archaeology Children Elder Care Environmental Conservation Healthcare Human Rights Organic Farming Ranching Special Needs Sports Teaching Trail Building Wildlife Conservation
Other
If you could do anything on a GY what would it be?
Captcha: Please type what you see
	Reload

As a reminder, to select (or unselect) your possible Gap Year choices in a multiple choice drop-down box above, in Windows hold down the CTRL key, in MAC hold down the Command key, then click your choices.