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Southeast Asia Youth Leadership Program Myanmar Student Application Application Deadline: January 2, 2012 Program Description: Students and educators are invited to apply for participation in the Youth Leadership Program with Southeast Asia. The program will employ a highly interactive approach both in workshops and in a range of public and community settings. Through engagement in the activities of U.S. high schools, community organizations, youth groups, and community leaders in each location, the student and adult participants will better understand civic participation and the rights and responsibilities of citizens in a democracy. The program will be intensive, academic, and highly interactive. The program sponsors seek energetic applicants who are ready to develop their skills in order to be effective leaders in their schools and communities. Students who may apply are those who:  Will be at least 15 years old and not more than 17 years old during the program (born between April 10, 1995 and April 10, 1997)  May be high school or first year college students  Have good English skills, sufficient for understanding academic discussion and everyday social interactions  Have permission from both parents and schools to participate in the entire program. Instructions for completing this application: Please fill out the application in English as completely as possible. The information you provide on this application will provide the basis for selecting semi-finalists for this program. Answer the questions carefully and completely. Applications should be submitted to: RangoonUSECA@state.gov (or) American Center, 14 Tawwin Street, Dagon Township (Only computerized or typed (NOT HAND-WRITTEN) application form will be accepted.) This Application is free of charge and may be duplicated. Southeast Asia Youth Leadership Program: Myanmar 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: Paste or staple a recent passport-size photograph here (Words except last word of your name) Complete Name: Nickname: Female Birth date Male Day Month Year Address 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 This Application is free of charge and may be duplicated. 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 additional space as needed. 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? This Application is free of charge and may be duplicated. Essay Questions Please answer the following questions in the space provided. 1. Why is participation in this program important to you and how will it benefit your community? 2. What do you see as the qualities of a good leader? Describe someone you know personally who you admire as a good leader and explain why. 3. Describe a challenge you have faced and how you overcame it. This Application is free of charge and may be duplicated. Is there anything else you would like us to know about you? More about you: Do you have a valid passport? Yes No If yes: Issuing Country Expiration Date Passport Number (day/month/year) Have you ever lived and/or studied in the United States or in another country? Yes If yes, where, when, and why? Signatures: 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 Date This Application is free of charge and may be duplicated. No SOUTHEAST ASIA YOUTH LEADERSHIP PROGRAM 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. Applicant Name For the Reference: The student named above is applying to take part in a the Youth Leadership Program with Southeast Asia, a 25-day exchange program in the United States for students and teachers. 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 This Application is free of charge and may be duplicated. SOUTHEAST ASIA YOUTH LEADERSHIP PROGRAM Reference (2) 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. Applicant Name For the Reference: The student named above is applying to take part in a the Youth Leadership Program with Southeast Asia, a 25-day exchange program in the United States for students and teachers. 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 This Application is free of charge and may be duplicated.