New Customer Registration Form

Let's connect

After completing this form, one of our EF Gap Year Consultants will reach out to schedule a time to talk in more detail about which of our programs is right for you. For U.S. students ages 18–22.
Let's connect

After completing this form, one of our EF Gap Year Consultants will reach out to schedule a time to talk in more detail about which of our programs is right for you. For U.S. students ages 18–22.
TRAVELER FIRST NAME*
TRAVELER LAST NAME*
TRAVELER EMAIL*
TRAVELER PHONE NUMBER*
PHYSICAL & MENTAL HEALTH HISTORY
Self-assessment to be completed by the participant. Select below if you have ever been diagnosed with or have experienced any of the following conditions. Hold down the control button or command button to select all that apply. Select "none" if none apply:
Comment on any conditions checked above, or list any other conditions. Provide as much detail as possible, including severity and if the condition is current or resolved.

0/10000
ALLERGIES
Self-assessment to be completed by the participant. Select below if you have ever been diagnosed with or have experienced any of the following allergies. Hold down the control button or command button to select all that apply. Select "none" if none apply:
Comment on any allergies checked above, or list any other allergies. Provide as much detail as possible for each allergy: trigger foods, flora, fauna; severity of reaction; medications for managing symptoms and reactions; and emergency use of epinephrine.

0/10000
MEDICAL TREATMENT
Have you been treated by a doctor for any significant physical or mental health issues in the past 12 months? This may include, but is not limited to, physical disabilities, known medical conditions, known allergies or dietary restrictions, current medications and treatments, mental or psychological disabilities, learning disabilities, and known behavioral conditions:
Have you had any hospitalizations or surgeries? If yes, please provide as much details below as possible, including the type and month/year of surgery or hospitalization.

0/1000
Please list any prescription medications you are currently taking and provide the dosage and reason for use.

0/10000
FITNESS & WELLBEING
Self-assessment to be completed by the participant. Our programs can present physical and mental challenges due to their fast-paced nature, which may be outside travelers' familiar comfort zones. Successful program participants must be able to meet all of the following essential eligibility criteria. Please confirm this by checking each box. If you are unable to meet any of these criteria, please contact us to discuss further.
Maintain a positive attitude and exhibit a willingness to try new things.Travel independently abroad, including internationally from the U.S., between program modules, and on public transportation in host cities.Be able to manage your own luggage and lift up to 40 lbs.Be able to follow directions, complex instructions, and accept positive feedback.Manage daily personal care, and cope with various environmental challenges (heat, cold, altitude, insects, changes in diet).Walk unassisted for several miles.Effectively and proactively communicate with staff if you are in pain or under stress and need assistance.Be able to exercise independent judgment in the absence of direct supervision.Be able to self-administer ongoing medical treatment while away from home support systems and with professionals through telephone or video chat, if necessary.Practice self-management techniques in relation to mental health and self-care, including the use of de-stressing habits such as journaling, exercise, meditation, yoga, deep breathing, proper sleep routines, peer support, etc.Take responsibility for your own self-care and manage any known medical and mental health conditions with a robust support and communication plan between you and your physician(s).If taking prescription medications, be able to independently manage storage, dosage and administration.Bring a sufficient amount of medication to last for the duration of the EF Gap program.
Comment on any concerns or additional well-being support you might need from EF Gap Year to successfully complete your program abroad.

0/1500
By checking this box I confirm the above information is an accurate and complete representation of my physical and mental health history.
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Should be Empty:

Abdominal issues
ADD/ADHD
Anemia
Anxiety
Arthritis
Asthma
Autism/Asperger's
Back issues
Bipolar disorder
Bladder/kidney
Bleeding/clotting disorder
Blood disorder
Blood pressure issues
Cancer/Leukemia
Celiac disease
Cerebral palsy
Chest pain
Chronic condition (comment details below)
Chronic pain
Depression
Dizziness/faintness/balance issues
Diabetes
Ear/nose/throat issues
Eating disorders
Epilepsy/seizures
Gastrointestinal disorder
Head injury/concussion
Hearing issues
Heart murmur/disease
Hepatitis
Immune system issues
Learning disability/differences
Limited use of limbs
Joint pain/issue
Measles
Migraines/severe headaches
Motion sickness
Neurological disorder
Phobias
Polio
Respiratory conditions
Skin conditions/disorders
Sleep issues
Speech impairment
Substance use/abuse
Suicide ideation/attempt
Thyroid disorder
Tuberculosis
Vision/eye issues (uncorrected)
Vision/eye prescription (corrected)
Other (list below)
None