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 __________________________________
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 ____________________________________________________
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.
|Costa Rica||Eastern Europe||Ecuador||England||Europe|
|South America||Spain||Spanish Speaking||Thailand||Vietnam|
|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|
|Animals||Archaeology||Architecture||Art History||Big Game|
|Farming||Fashion||Film||Guitar Making||Health Care|
|Marine Bio||Martial Arts||Media||Museums||Music|
|Scuba||Social Justice||Special Needs||Spiritual||Sports|
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:
19 Whitcomb Road
Scituate, MA 02066
19 Whitcomb Road
Scituate, MA 02066