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Student Application

About you:Please print your name clearly exactly as it appears on your passport.

Last (Family) Name: (Last word of your name)        
First Name:    
Birth date Day   Month   Year  
City, Postal Code  
Telephone   Email Address  
City & Country of Birth  
Country of citizenship or permanent legal residence  

About your family:

Parent or guardian name(s)  
Address (if different from yours)  
Father Telephone   Email  
Mother Telephone   Email  
Brothers/ Sisters Name Gender Age Occupation

About your education:

School name  
School address  
City, Postal code  
Current Grade   Year you will graduate  
How many years have you studied English?  
Do you speak any other languages besides your native language and English? Which ones?


About your academic and community interests:


Academic subjects you are most interested in:  
Please describe the activities (extracurricular, community, hobbies) in which you have participated, how long you have been involved with each, any awards or honors. Use the space provided.  
Future studies and/or possible occupations you’ve considered    
  Can you identify a specific issue or problem affecting your school, neighborhood, or community? What might you do to help resolve this problem? Use extra paper if needed.    

Essay Questions

1. Describe one strength and one weakness of your community (school, city, country). What are the causes of these strengths and weaknesses? Limit your response to 500 words or less. Responses longer than 500 will not be considered.    
2. How are you a leader in your school or neighborhood? Identify two to three leadership qualities that you have and examples of how you use them. Limit your response to 500 words or less. Responses longer than 500 will not be considered.      
3. Describe an experience or challenge that you have overcome. How did you overcome it? What did you learn from that experience? Limit your response to 500 words or less. Responses longer than 500 will not be considered.      
4. What knowledge, skills and abilities do you hope to gain as a result of participating on this program? Who else would benefit from your participation on this program?  

More about you:

Do you have a valid passport? Yes   No    
If yes: Issuing Country      
  Passport Number   Expiration Date (day/month/year)  
Have you ever lived and/or studied in the United States or in another country? Yes   No  
If yes, where, when, and why?  




All information in this application is accurate and true
Applicant Signature   Date  
I permit my son/daughter to apply for and, if selected, to participate in this program
Parent or guardian signatures:   Date  


Reference (1)


For the Applicant: Below, fill in your name and give this form to a teacher or other adult outside your family who knows you well. Ask the reference to fill out the form and return it to: ________________.


Applicant Name  


For the Reference: The student named above is applying to take part in Youth Leadership Program, a 22-day exchange program in the United States. The selected students will be in a challenging academic environment and intensive leadership training. To succeed, the participants must be highly motivated, and be able to adjust to living and working with people of different social and cultural backgrounds. We value your honest assessment of the applicant in helping us select the most appropriate participants. If you would like to add additional comments, we encourage you to do so. Your answers will remain confidential.


Please indicate your opinion of this applicant’s ability to meet the challenges of this program.
    I strongly recommend this student
    I recommend this student
    I have minor reservations about recommending this applicant
    I have major reservations about recommending this applicant
    I do not recommend this student


How long, and in what context, have you known this applicant?
What are the applicant’s strengths?
What are the academic or personal areas in which this applicant needs more development?
Please describe the applicant’s behavior with respect to authority, peer relationships, and activities.
Do you think the applicant would adapt well to unfamiliar environments and new situations? Why or why not?


Name (printed)  
Signature Date  

Date: 2015-12-11; view: 958

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