Act Five Gap Year Program Application

(2025-2026 cohort)

We are excited that you have decided to start an application to Act Five's gap year program! If you have any questions during this process, don't hesitate to contact us.

The Basics

First Name *

Middle Name

Last Name *

Your Address

Address Line 1 *

Address Line 2

Postal/Zip Code *

City *

Country *

Province/State *

Your Contact Information

Email Address *

Preferred Phone *

Cell Phone

Gender

Birthdate *

Primary Citizenship *

Secondary Citizenship

How did you hear about us?

Next Step

The Big Picture

Please answer the following question in the space below as best as you are able

Why would you like to participate in Act Five? *

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The People

Personal Reference

Please provide us with a contact who is able to serve as a personal reference for you (please ask this person before including them here).

This should be someone who knows you well and can speak about your faith and character, whether having served as your teacher, coach, youth pastor, camp director, or similar (not a family member). Upon receipt of your application, your reference will receive a separate form from us to complete.

Personal Reference First Name *

Personal Reference Last Name *

Personal Reference Relationship *

Personal Reference Email *

Personal Reference Phone *

Academic Reference

Please provide an academic reference as well. This should be someone who can speak to your academic experience throughout high school.

Academic Reference First Name *

Academic Reference Last Name *

Academic Reference Relationship *

Academic Reference Email *

Academic Reference Phone *

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Before you submit this application, here's your chance to share any final pieces of information with us that you think would be good for us to know.

Share anything extra here

Signature

Full Legal Name *

Date of Signing *

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