Sending Program Pre-Application —WKESB/tm

1 1. PERSONAL INFORMATION i Complete name as appears in NSO birth certrflcate/passport: (Last / First / Middle) Birthdate: (mm/dd/yy) Gender

• Male • Female

Complete home/mailing address: (House No., Street, Barangay, City/Municipality, Province) Region: Zip Code:

Home phonew/area code: Mobile phone/s: Email/s:

| Name of Father/Legal Guardian (for minora): Name of Mother/Legal Guardian (for minors):

j Job/Occupation & Employer Name: Job/Occupation & Employer Name:

| Work or Mobile Phone/s:

j

Email/s: Work or Mobile Phone/s: Email/s:

1 Passport No. (if available):

\ <

Passport issue date: Passport expiry date: City/Country issuing passport:

Religion: • Christianity • Islam • Other

1 am aMergic to: Foods 1 cannot eat: Native/Foreign languages spoken:

Family/relative who has participated in an AFS Program:

• Yes, 1 have an AFSer relative. • No, 1 don't have an AFSer relative.

No. of Sibtngs (brothers/sisters):

IF yes, name of AFSer relative: Relationship: Program Name/Destination: Date/Month/Year of Departure:

AFS Programs: 1 learned about AFS through

•AFS returnee/alumni/volunteer •School DFriends/relatives Dlntemet OPrint (newspaper/brochure/oostert OOther

II. SCHOOL/EMPLOYER INFORMATION Complete school/company name:

Complete school/company mailing address: (House No., Street, Barangay, Clty/Municipalty, Province) Region: Zip Code:

Complete name of school principal/administrator/immediate supervisor:

Telephone/s: Fax: Email/s: Mobile Phone/s:

For student only: Year Level in June 2012 For student only: Avenge grade in previous school yean

For Teacher only: PRC License Number For Adult only: Marital Status & No. of dependents:

i l l . AFS PROGRAM SPECIFIC II Y FORMATION Core Program Duration:

1 choose to go abroad on: j/ftear Program (YP) • Semester (SM) Program • Tri-mester (TP.) Program • Intensive Program (IP) • Very Short (VS) Program

t choose to start my travel on: • January-June (SH cycle)

^July-December (NH cycle)

Program Content:

a" r High school • University • Community Service • Class Exchange • Culture Study & Immersion • Dance • Eco-Tourism • Educator • English language • Intensive Foreign language • Internship a Journalism • Sports • Teacher assistant • Volunteer

• Other:

Preferred AFS Patner:

1 choose to go to an AFS destination/host country in:

• Asia • Europe

JZfKtorth America • South America • Africa

My top 3 destinations are:

1. 2. 3.

Scholarship Information:

B ACS Aao and tho Pacific Initiative (AAI) Scholarship

B AES International Diversity Scholarship

Core Program Duration:

1 choose to go abroad on: j/ftear Program (YP) • Semester (SM) Program • Tri-mester (TP.) Program • Intensive Program (IP) • Very Short (VS) Program

t choose to start my travel on: • January-June (SH cycle)

^July-December (NH cycle)

Program Content:

a" r High school • University • Community Service • Class Exchange • Culture Study & Immersion • Dance • Eco-Tourism • Educator • English language • Intensive Foreign language • Internship a Journalism • Sports • Teacher assistant • Volunteer

• Other:

Preferred AFS Patner:

1 choose to go to an AFS destination/host country in:

• Asia • Europe

JZfKtorth America • South America • Africa

My top 3 destinations are:

1. 2. 3.

B AES Mabuhay ScholarGhip • Kamenori Scholarship Year Program

^kennedy-Lugar Youth Exchange & Study (YES) Program, Tl months

S Wiajro SM Program. 6 months • Kizuna VS Program, 12 days • Leighton Philippines Year Program

Scholarship, 11 months • Philippine Youth Leadership Program

(PYLP, 5-4 weeks) • Other

Core Program Duration:

1 choose to go abroad on: j/ftear Program (YP) • Semester (SM) Program • Tri-mester (TP.) Program • Intensive Program (IP) • Very Short (VS) Program

t choose to start my travel on: • January-June (SH cycle)

^July-December (NH cycle)

Complete name as appears in NSO birth certificate/passport: (Last /First /Middle)

Program: Pre-Application p. 2

Tell us about yourself: Introduce yourself (I.E, how you see yourself, your personality, your relationship with your family and friends, your responsibilities at home and at your school, list your favorites, interests and hobbies, organization memberships, volunteer initiatives, and indicate how often you pursue them, etc Please attach separate sheets, as needed.)

Tell us about your expectations (before, during & after) for the program that you are applying for:

Tell us about your goals or plans which are important to you; what is your chosen community service advocacy?

I hereby certify that all information provided in this application form are true and correct to the best of my knowledge and ability. Applicant's signature: (Additional signature of Parent/s or legal guardian is required, if applicant is a minor.)

Date of application: (mm/dd/yy)

Date received by AFS voi/staff:

SUBMIT Online Applications at: https://www.afsgiobal.org/AFSGIobal/OnlineApplication

ATTN: SENDING PROGRAM

AFS InterculturaJ Programs Philippines Foundation, Inc. Unit 1607 K/F Antei Global Corporate Center No. 3 Dofla Julia Vargas Avenue, Ortigas Center 1600 Pasig City, Metro Manila, Philippines

Telefax: +62(2)584 2002 • Email: info.ptiilippmesaafs.org • Web: http://www.afs.ph

Page 2 o f 2