YES PRELIMINARY APPLICATION FORM 2013 – 2014

Instructions for completing this application: All sections of this five-page application for the

Youth Exchange and Study (YES) Program must be fully completed in order to be considered for

the next step – which is English language testing. Missing information will delay the processing

of your application.

I. STUDENT INFORMATION:

Please write your name as it appears in your passport.

______

First Name Middle Names Last Name

Do you ever spell your name differently? If so, how: ______

Please write your nickname(s) or the name(s) that your friends at school or home call you.

______

E-mail: Mobile Number:______

Address: ______

City:______ Country:______

Home Phone:______Permanent Residence:______

Citizenship:______Birth Date (mm/dd/yyyy):______

City of Birth:______Country of Birth:______

Are you a U.S. Citizen or do you have a U.S. Passport?

Have you ever applied for a green card or a U.S. permanent residency?

II. FAMILY INFORMATION:

Father’s Data:

First Name:______Last Name______

Occupation:______Mobile:______

Mother’s Data:

First Name______Last Name______

Occupation:______Mobile: ______

III. EDUCATION:

Name of School: ______

School Director’s Name:______

School Address: ______

School Phone: ______School E-mail: ______

What grade level are you currently in?______

Number of years of English Study: ___ Last Year’s final English grade: ____

Last Year’s overall cumulative grade point average:____

IV. INTERESTS AND HOBBIES:

List all school activities and all hobbies you have or in which you have participated. Start with

The most recent:

______/ ______/ ______/__

Activity Number of Month/Year Month/Year

Hours/Week Started Ended

______/ ______/ ______/ ______

Activity Number of Month/Year Month/Year

Hours/Week Started Ended

Have you received any awards, or do you have any outstanding achievements in the activities

listed above?

______/ ______/ ______

Name of Award/Achievement Reason for receiving Award Date received

______/ ______/ ______

Are there any activities you would like to pursue or to learn while an exchange student in the

U.S.?

V. FUTURE PLANS:

Do you intended to continue your education upon completion of secondary school? _____

If yes, where? ______

What do you intend to study?

What are your future job or career plans?

VI. WRITING A SHORT ESSAY:

Please answer the following essay question with a small paragraph of at least 50 words. You should present the information in a way that would help the YES screening committee understand you better as an individual.

  • Describe a situation when you organized an activity for your friends, school class or club.

Why did you organize it? What was the result?

Parent signature for consent to Participate in the program:______

Thank you! We will contact you regarding your eligibility to participate in an English

language exam.

YES Preliminary Application Form1