CHAPERONE INFORMATION

Toledo Sister Cities International

2018 International Youth Academy Application

July 22, 2017 – August 4, 2018

Please complete the following questionnaire. This will help in the planning of IYA and enable our host families to more easily get to know you. Please print clearly and use the same information that is on your Passport.

1. Your family name ______Given name ______

Name exactly as it appears on passport______

Birth date ______

2. Your address______

______

______

3. Your phone number______

(Please include country code when calling from the United States)

4. Your e-mail address______

5. Your school______

6. Are you a _____ Male or _____Female

7. T-Shirt Size _____Small _____Medium _____Large _____X-Large _____XX-Large

Please tell us why you would like to participate in the InternationalYouthAcademy. Also, please tell us what you are most interested in gaining from your experience staying in Toledo.

______

______

8. Names and ages of your spouse and children

Spouse______

Children______

9. What subjects do you teach? If you are not a teacher, what kind of work do you do?

______

______

10. Hobbies and Interests

Do you like:

a. to read books?_____Yes_____ No

b. to read newspapers?_____ Yes_____ No

c. to read magazines?_____Yes_____No

d. to go to movies?_____ Yes_____ No

Which movie is your favorite?

______

e. to play musical instruments?_____ Yes_____ No

What instruments do you play?

______

f. to listen to music?_____ Yes_____ No

What kind of music to you like best?

______

g. to watch TV?_____Yes_____No

How much time to you spend

watching TV each day? ______

h. to do handiwork or crafts?_____ Yes_____ No

What do you like to do?

______

i. to participate in or watch sports?_____ Yes_____ No

Which sports? ______

______

j. to use computers?_____ Yes_____ No

How much time to you spend

on computers each day? ______

k. to participate in clubs? _____Yes_____ No

In which clubs are you a member?

______

______

l. to travel?_____Yes_____No

Where have you traveled?

______

______

Please list any other activities or hobbies that you enjoy

______

______

______

11. How much time do you spend daily using the internet? ______

using your cell phone? ______

12. Foods

  1. Do you like to try different foods?_____Yes_____No
  1. What are your favorite foods?

______

______

  1. What foods do you not eat at all?

______

  1. Are there any foods that you are allergic to? ______
  1. Can you cook any foods specific to your country or region? ______

______

13. What foreign languages have you studied?

______

How long have you studied each language?

______

Have you had opportunities to practice these languages outside of teaching? Yes _____ No_____ Explain ______

14. Activities while in the U.S.A.

While you are at the IYA, which of the following activities will be of special interest to you? Check all that apply.

  1. historical places_____
  2. museums_____
  3. hiking_____
  4. music_____
  5. businesses_____
  6. shopping_____
  7. sporting events_____
  8. talking with people_____
  9. city life_____
  10. country life_____
  11. art _____
  12. other_____ list what that is ______

15. Health

a. My health is _____ Excellent _____Good_____Bad

b. Do you take medications regularly?_____ Yes_____ No

If “yes,” which medications to you take?______

c. Does your health require a special diet?_____ Yes_____ No

If “yes,” what foods do you require?

______

d. Do you have any allergies?_____ Yes_____ No

If “yes,” what allergies do you have?

______

16. About you:

What kind of person are you?

______quiet_____excitable _____chatterbox

______shy_____bookworm_____ athlete

______introvert_____extrovert

17. What kind of pets do you have at home?

______

18. a. Do you regularly drink alcoholic beverages?_____ Yes_____No

b. Do you smoke? _____ Yes_____ No

c. Does it bother you if others near you smoke?_____ Yes_____ No

I am applying to participate as a chaperone in the Toledo Sister Cities International Youth Academy Program

Have you ever traveled to the United States______Yes ______No

If yes, when, where, and what did you do during your visit: ______

______

Chaperones are permitted to participate only one time in IYA. By signing this document, I certify that I have not participated in IYA before and that the answers on this application are accurate.

Chaperone’s name (print) ______

Chaperons’s signature______

Home City International Association approval signature:

Official’s name (print) ______

Official’s signature ______

By April 30th, please send your $25.00 application fee with this document. This application fee is non-refundable in the event that you cancel your participation in the IYA.

Application Deadline April 30, 2018