_______________________
Please print the questionnaire (click here to open the pdf)
The questionnaire is designed to help you focus on some areas you will need to consider as you explore the idea of taking time away from your comfort zone. Most people never get to think about what they would do if the had the time so go for it. This questionnaire is a way to begin the process. Think about what you enjoy; how you like to spend your time, what you want to explore (experience not a pre-requisite for most options), what you will probably never get to do again or what you might want to do in the future. Add anything else you feel is pertinent. Please print clearly.
Name ________________________________________________ Age/ DOB ________________________
Home Address ___________________________________________________________________________
Current Address _________________________________________________________________________
Home Phone ______________________________ Current Phone __________________________________
E-mail _________________________________________________________________________________
Parent’s Names ______________________________ Married/Divorced/Other (Please Explain) _______________
Parent’s address/ phone if different from above _________________________________________________
_______________________________________________________________________________________
Mother’s Occupation_________________________ Email _______________________________________
Father ’s Occupation_________________________ Email _______________________________________
What have you budgeted for the length of time you hope to be away? We need this information to make sure we can help you develop a realistic plan.
Are you looking for help in figuring out what you want to do or do you feel that you have a clear sense of how you want to spend your time? Need help Clear sense
How many experiences do you hope to have?
When do you want to leave and for how long?
What language(s) have you studied and for how long?
Are you interested in learning a language(s)? Please list.
Please list high school and college, what year you are in or when you graduated.
High School ______________________________ Fr/So/Jr/Sr Expected Graduation __________
College __________________________________ Fr/So/Jr/Sr Expected Graduation __________
If you are not in school or beyond this stage of your life what are you doing now and why are you exploring time away?
For location/lifestyle/interests either cross off what you don’t want and/or circle what you do want.
Please add locations/lifestyles/interests that interest you but are not listed below.
Location
Alaska |
Africa |
Amazon |
Andes |
Argentina |
Asia |
Australia |
Brazil |
Bolivia |
Cambodia |
Canada |
Caribbean |
Central America |
Chile |
China |
Costa Rica |
Eastern Europe |
Ecuador |
England |
Europe |
France |
Ghana |
Guatemala |
Greece |
Hawaii |
India |
Ireland |
Israel |
Italy |
Japan |
Laos |
Mediterranean |
Morocco |
Mexico |
Mozambique |
Nepal |
Nicaragua |
New Zealand |
Pacific |
Peru |
Scotland |
Senegal |
South Africa |
South America |
Spain |
Tanzania |
Tibet |
USA |
Vietnam |
Zambia |
Lifestyle
Academic |
Non Academic |
College Credit |
Indoors |
Outdoors |
Rural |
Urban |
Office |
Stay in one place |
Travel |
Hot Shower |
Roughing it |
Home stay |
Student Apartment |
Wilderness |
Cultural Immersion |
Physical Labor |
Part of a Group |
With Americans |
People your own age |
Interests
Wildlife |
Children |
Painting |
Hiking |
Certifications /Courses |
Whales |
Orphans |
Drawing |
Trekking |
Scuba |
Dolphins |
Special needs |
Sculpture |
Rainforest |
Biological Survey Techniques |
Penguins |
Women |
Ceramics |
Sustainable Development |
Equestrian training |
Sharks |
Refugees |
Film |
Gardening |
Mountaineering Guide |
Seals |
Native American |
Photography |
Farming |
Game Ranger |
Big Game |
Elderly |
Music |
Environment |
GIS Geographic Information System |
Leopards |
Health Care |
Fashion |
Sailing |
Field Research |
Pandas |
HIV/AIDS |
Art History |
Ocean |
Sail/Yacht Instructor |
Elephants |
Social Justice |
Media |
Marine Biology |
Safari Field Guide |
Horses |
Language |
Journalism |
Sports |
Skiing/Back Country Skiing |
Monkeys |
Archaeology |
Writing |
Reef protection |
Guitar Making |
Bears |
History |
Technology |
Surfing |
Boat Building |
Turtles |
Museums |
Graphic Design |
Martial Arts |
Architecture |
Cheetah |
Politics |
Yoga |
Spiritual |
Wildlife Film |
Vet Medicine |
Construction |
Dance |
Conservation |
EMT |
Please rank the following in terms of their importance in planning your year.
(1 = most important; 10= least important)
Where you go _____________ What you do_____________ Whether you are with a group of your peers___________
Please explain prior travel. If you have done other programs, please list.
What are your strengths?
What gets in your way?
Please list any physical, medical or psychological conditions for which you have been treated and medications you currently take and why (e.g. ADHD, diabetes, alcohol/drug addiction, depressive disorders, asthma, etc.). The information will be kept confidential and has nothing to do with your ability to participate in 99% of the above areas of interest. Many organizations require medical forms but that is information that you and your doctor share with the organization and does not come through us.
If you have a resume, please email or include with your questionnaire. If not, please list and indicate any volunteer, school, internship or paid positions you have held?
How do you hope to spend your time off? Please use as much space as you need. If you don’t have a vision yet, we are here to help.
Send, email or fax your questionnaire to the information below
takingoff@takingoff.net Fax 1 617 344 0481
Gail Reardon Taking Off 12 Marlborough St. Boston, MA 02116 USA
Thank you for taking the time to fill out the questionnaire.
Once we receive your questionnaire we will be in touch so please print clearly.
