Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birth Date *

MM

DD

YYYY

Have you ever been diagnosed with any of the following? *

You can select more than one.

ADHD or ADD

Depression

Disordered Eating

Learning or Processing Challenge

Obsessive-Compulsive Disorder

Panic or Anxiety Disorder

Substance Abuse

Other Mental, Social, or Emotional Health Issue

No, I have not

Are you currently seeing a therapist, psychiatrist, or other mental health professional? *

Yes

No

In the past three years, have you been asked to leave school, summer camp, or another program? *

Yes

No

In the past three years, have you been treated for any physical or psychological condition that severely limited your ability to participate in any activity? *

Yes

No

In the past three years, have you been arrested for a criminal offense? *

Yes

No

Reference #1 *

Name

First Name

Last Name

Phone

(###)

###

####

Reference #2 *

Name

First Name

Last Name

Phone

(###)

###

####

How did you hear about Gap at Glen Brook? *

Gap Year Association website

Internet search

Educational Consultant or Gap Advisor

School Guidance Office

From a Gap Year Fair

Word of Mouth

GoOverseas website

GoAbroad website

TeenLife website

Social media

Other

By checking this box, below, I state that I have read and understood the three documents linked on the top of this page (Essential Eligibility Requirements, Community Policies, and Terms and Conditions) and that I agree to the stated Community Policies as well as the Terms and Conditions. *

Yes, I agree