A one-year project that covers workshops and learning activities, including a four-week

U.S.-based study and exposure period from April 11 – May 7, 2015 focusing on

responsible citizenship, community service leadership and action plan development.

APPLICATION FORM: STUDENT PARTICIPANT

PERSONAL INFORMATION:

First Name (CAPITALS please): ______

Middle Name (CAPITALS please: ______

Last Name (CAPITALS please): ______

□ Male□ FemaleAge: ______Date of Birth: ______

Religion: ______Ethnicity /Tribe: ______

Home Address: ______

______

Permanent Contact #:______Email:______

Grade Level/Year & Course: ______

Grade average: For 3rd Year high school,submit latest form 138 or that from 2nd grading period SY 2014-2015; first semester SY 2014-15 for 1st Year college: ______

Please write down any special skills that you have:

______

PARENTS’ INFORMATION:

Father’s Name (CAPITALS please): ______

Birthday: ______Birthplace: ______

Ethnicity /Tribe: ______Occupation: ______

Mother’s Name (CAPITALS please): ______

Birthday: ______Birthplace:______

Ethnicity /Tribe ______Occupation: ______

Parents’Address (if not the same as above): ______

Father's permanent contact #:______Mother's permanent contact #: ______

SCHOOL / INSTITUTION INFORMATION:

Name of school: ______

Address: ______

Name of school head: ______

Permanent Contact #:______Email:______

PARTICIPATION IN SCHOOL- and COMMUNITY-BASED ACTIVITIES:

Membership in school organizations and civic clubs at least as far back as two years to the present. Please attach authenticatedphotocopies of proof of membership by the organizer or school adviser and activity participation record.

______

______

Membership in other organizations or non-government organizations (NGOs at least as far back as two years to the present. Please attach authenticated photocopies of proof of membership by the organizer or school adviserand activity participation record.)

______

Titles and dates of other workshops participated in related to peace-building, leadership and environment at least as far back as two years till the present. Please attach authenticated photocopies of certificates of attendance or participation by the organizer or school adviser:

______

______

______

OTHER REQUIREMENTS:

  1. Two essays: On at least one sheet of paper, please write something about yourself. On another sheet (at least one page), please share with us your vision for your community. Please attach these when submitting this application form.
  1. Documents

a) Scanned or photocopy of birth certificate (preferably issued by the National Statistics Office/NSO)

b) Scanned or photocopy of high school report card or first semester grades in college

c) Scanned or photocopy of certificates of membership in organizations

d) Scanned or photocopy of Certificates of Participation in seminars/workshops

e) Scanned and original copy of endorsement of your application by your school

f) Signed consent by parent(s) or guardian at the bottom of this form, and on the right-hand

side margin of the first two pages of this form.

CERTIFICATION AND CONSENT

I hereby certify that I have read and understood all sections of this form and that all facts and information placed herein are true and correct to the best of my knowledge. I further declare that any information given by me that may be untrue will be grounds for disqualification to the program.

Further, I subscribe and agree that the PYLP Selection Committee has the sole prerogative to select and nominate the delegates, and its decision is final and executory.If selected as a participant, I commit to participate actively in all the activities of the program.

(Signature over printed name of applicant) / Date:

PARENT(S) OR GUARDIAN’S CONSENT TO PARTICIPATE IN THE PROGRAM:

Father/Guardian
(Signature over Printed Name) / Mother/Guardian
(Signature over Printed Name)

Date:Date:

When submitting applications, please ensure completeness of information and requirements specified. Applications may be received by any of the following coordinators and/or contact persons:

Maguindanao, South Cotabato and Sarangani Province

Al Quillope

Email: / Phone #: (0921) 5600702

Notre Dame of Marbel University, Koronadal City, South Cotabato

Allan Remedios

Email: / Phone # (0908) 625 4393

Holy Trinity College, Gen. Santos City

Cotabato City, Sultan Kudarat, North Cotabato

Victoria F.D. Bat-og

Email: / Phone #: (0918) 768 1478

Southern Christian College, Midsayap, North Cotabato 9410

Susan S. Anayatin

Email: / Phone # ( 0917) 7267828

DTI-ARMM Regional Office, ORG ARMM Compound, Cotabato City

Aldrin Flores Quintero

Email: / Phone # ( 0939) 5861821

Kalawag II, Isulan, Sultan Kudarat

Misamis Oriental, Lanao del Norte, Lanao del Sur, Bukidnon, Zamboanga del Sur

Mona Lisa Pangan

Email: / Phone #: (0906) 4411509

Campus Ministries Office, Xavier University, Cagayan de Oro City 9000

Akizah Busran Cauntongan

Email: / Phone # 0946-1860024

Riverside, Kolambugan, Lanao del Norte

Mohamad Jamsheed Abdul

Email: / Phone # (0915) 5665040

American Corner, Marawi State University, Marawi City

Zamboanga City, Zamboanga del Norte, Zamboanga Sibugay, Sulu, Tawi-Tawi and Basilan

Aldrin Abdurahim

Email: / Phone #: (0927) 863 9485

Office of the Student Regent, Western Mindanao State University, Baliwasan 7000Zamboanga City

Cecille Ancheta La Plana

Email: / Phone#: (0927) 57819142

Purok Orchids, Tirso Babiera Dr., African Daisy St.

Poblacion, Ipil, Zamboanga Sibugay 7001

Mohamad Ali Esmael Ramber

Email: / Phone # 0916-7341661

Purok Sunshine, Alano St., Santiago, Pagadian City

Davao City, Davao del Norte, Davao del Sur & Davao Oriental

Jana Jean Dacobor

Email: / Phone #: (0917) 716 9023

Bishops-Ulama Conference

Matina 8000 Davao City

Coordinating Center:

Dr Lourdes Tolod

Email: / Phone #: (0917) 716 9292

School of Education, Xavier University

Cagayan de Oro City 9000

Notes:

  1. Shortlisted Applicants will be directly notified as to date and location of the final interview.
  1. Applicants who have family members (father, mother, sister or brother) and cousins within the first degree of consanguinity who have participated in any US Department of State sponsored grants are no longer qualified to participate in this program.

PYLP 12 Youth Application Form Page 1 of 5