Youth Leadership Program: Fiji, Tonga, Tuvalu

Personal Information

Name*

First Last

Gender*

Address*

Street Address Address Line 2 City Country

Home Phone*

Mobile Phone*

Email

Date of Birth (day/month/year*

Age as of August 1, 2021 (you cannot be less than 15 years old or more than 18 years old at time of program)*

City and Country of Birth*

Country or citizenship or permanent legal resident (Note applicants with dual U.S. citizenship are ineligible)*

Parent/Guardian Information

Parent/Guardian 1: Name*

Relation to you*

Address (if different from yours)

Phone*

Email*

Occupation*

Parent/Guardian 2: Name*

Relation to you*

Address (if different from yours)

Phone*

Email*

Occupation*

Brothers/Sisters - list any siblings, gender and age

Travel Information

Have you ever traveled to the United States or another country?*

Yes
No

If yes, please provide a brief description of place, dates, length and nature of your stay(s).

Education

School Name*

School Address*

Location (town/city)*

Current Grade*

Year you will graduate*

How many years have you studied English?*

Please list other languages you have studied and the number of year studied:*

Future studies and/or possible occupations you have considered*

Activities

Please list all extracurricular activities in which you have participated or currently take part in (school clubs, sports teams, youth organizations, community service activities, leisure time activities), how long you have been involved with each, any awards or honors that you have received.*

Essay Questions - please respond in one paragraph (no fewer than 350 words)

1. Why do you want to participate in this program?*

2. In what ways have you demonstrated leadership in your school, community, or home? Give two examples.*

3. During this exchange, participants will conduct themselves as ambassadors for their countries. In this context, what would you like people to know about you and your country?*

4. What do you consider to be a pressing environmental issue in your community? Please explain.*

5. What device or devices do you use on a regular basis at home? Check all that apply.*

Select All
Smartphone
Tablet
Desktop
Laptop
Other

6. What sites on the internet do you use for learning or finding information?*

Select All
Internet Searches
Youtube
Khan Academy
Tedx Talks
Other

A Reference

Last step: Ask a teacher or coach to give you a reference. Send an email today asking him/her to complete an on-line survey by March 11. Copy and paste this link into your email - https://www.surveymonkey.com/r/Y3ZTKM2

Participant Agreement

Consent*

I agree.

I agree that all of the information in this application is true and I agree that if selected to be a part of this program, I will participate in ALL program activities, including the three-week virtual exchange and follow-on activities. I also understand that I must apply my full attention, work independently and as part of a team and complete assignments in a timely way.

Parental Consent - please make sure your guardian knows you are applying

Consent*

I permit my child to apply for and, if selected, to participate in this program.

Today's Date*

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