• scuba dscn0027 scuba kenya_benclark_175 me-dropping-in-on-a-wave-about-and-8ft-face img_2611

Questionnaire

For best results, please print our PDF – click here.

The questionnaire is designed to help you focus on some areas you will want to consider as you explore the idea of taking time away. 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, what you will probably never get to do again or what you might want to do in the future (experience is not a prerequisite for most options).  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

Siblings name/age  __________________________________
Parent’s address/ phone if different from above _________________________________________________

_______________________________________________________________________________________

Mother’s Occupation_________________________ Email _______________________________________

Father ’s Occupation_________________________ Email _______________________________________

How did you hear of Taking Off?

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.

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 ____________________________________________________

College ________________________________________________________

If you are not in school or are beyond this stage of your life, what are you doing now and why are you exploring time away?

For location, lifestyle and interests either cross off what you don’t want  or circle what you do want.

Please add any 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 French Speaking Guatemala Greece Hawaii
India Ireland Israel Italy Madagascar
Mediterranean Mexico Nepal Nicaragua New Zealand
Ocean Pacific Peru Scotland South Africa
South America Spain Spanish Speaking Thailand Vietnam
USA Worldwide

Lifestyle

Academic Ocean College Credit Travel/adventure
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

Animals Archaeology Architecture Art History Big Game
Boat Bldg Buddhism Ceramics Children Construction
Cooking Dance Dolphins Drawing Environment
Farming Fashion Film Guitar Making Health Care
Hiking HIV/AIDS Horses Journalism Languages
Marine Bio Martial Arts Media Museums Music
Painting Photography Rainforest Sailing Skiing/Snowboarding
Scuba Social Justice Special Needs Spiritual Sports
Surfing Teaching Theater Tourism Whales
Wilderness Wildlife Writing Women’s Issues Yoga

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?

List any physical, medical or psychological conditions for which you have been treated and medications you currently take and why.

If you have a resume, please email or include with your questionnaire. If not,  list 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.

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.

Send, email or fax your questionnaire  to:

Taking Off
19 Whitcomb Road
Scituate, MA  02066
1.617.424.1606(phone)
1.617.344.0481(fax)

takingoff@takingoff.net
Gail Reardon
Maureen Lavin-Arcand