Curious Kaleidoscope Application

CURIOUS K A L E I D O S C O P E

To apply for enrollment, please fill out all required boxes.
Applying for:*

Gap Year 2018
Participant Information
Participant First Name*
Participant Last Name*
Participant Nickname
Mailing Address*
City*
State
(or Canadian Province)
Zip/Postal Code*
Country*
Home Phone*
Cell Phone
Participant Email*
This should be an email address that you check frequently!
Birth Date*

MonthDayYear
Age at Start of Trip*
Gender*
Preferred Pronoun(s)*
Passport Status*

I have a valid passportI do not have a valid passport
Citizenship*
Adult Unisex T-shirt Size
Primary Adult Contact Information
First Name*
Last Name*
Daytime Phone*
Evening Phone*
Email*
Relationship (e.g. mom, uncle, guardian)*
If address is different than participant's address, please fill in below.
Mailing Address
City
State
or Canadian Province
Zip/Postal Code
Country
Second Adult Contact Information
(This parent, guardian, or other adult is our backup contact and will receive certain important emails.)
First Name*
Last Name*
Daytime Phone*
Evening Phone*
Email*
Relationship*
If address is different than participant's address, please fill in below.
Mailing Address
City
State
or Canadian Province
Zip/Postal Code
Country
Health Questions
Is the participant, or has the participant in the past 24 months been under the care of a physician, psychologist, or psychiatrist? (Ignoring routine check-ups.) *

YesNo
Is there any information about the participant's physical or mental health that might have some bearing on their trip?*

YesNo
Is the participant currently taking any prescribed medications?*

YesNo
If "Yes" to any of the above questions, please provide a short explanation:
Allergies
Diet*
Additional Dietary Restrictions
Participant Questions
Please answer the following prompts with 1-2 paragraphs each.
Why are you applying to this trip? What are you hoping to learn and carry with you into the next chapter of your life? *
Describe experiences you've had that make you feel ready to leave home for a long time. How do these experiences support your decision to apply to this program?*
What are you passionate about?What do you like to do for fun? What are you doing when you feel the most like yourself?*
Describe your "education."*
Can you navigate a small city or airport on your own?*

YesNo
Can you wake yourself up at a certain time if necessary, and can you keep track of time on your own? *

YesNo
Do you see any problems complying with the Curious Kaleidoscope Drug and Alcohol policies? *

YesNo
How did you find out about this trip?*
Submission
We only use application information for contacting parents/guardians concerning enrollment, billing, or emergencies. We respect your privacy and do not sell or rent your information to third parties. We do add emails to our notification list, which goes out a few times a year.

When you are ready to apply, please click "Submit". A copy of your application will be emailed to the participant and primary parent/guardian.
Should be Empty:

CURIOUS K A L E I D O S C O P E

Participant Information

Primary Adult Contact Information

Second Adult Contact Information

Health Questions

Participant Questions

Submission