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	None Mr. Mrs. Ms. Dr. Prof.
First Name*
Last Name*
Preferred Name
Sex at Birth*	Select Male Female
Additional Gender Information
Age*
Birthdate*
Interest Sheet Done	-None- No Yes
Street*
City*
State	-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*
Cell Phone*
Home Phone
Skype ID
In what countries do you hold citizenship?
Education
I am currently a -	Select 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 Information
Parent Contact Information This section to be completed by applicants who are 21 and younger.
Parents' Marital Status	Select 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 and Sisters	Select Yes No
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?	Select An Interim Client Family Book Directory College Office Education Consultant Family Member Gap Fair High School Counselor Internet LEAPNow News Article Psychiatrist Psychologist School Presentation Word-of-Mouth Other
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 had?
What hobbies do you have? What do you enjoy doing in your free time?
What subjects in & 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. 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)	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
Opportunities and Activities Please check all opportunities and activities that interest you, regardless of your experience.
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	Conservation 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 Voice
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 Chinese 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 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