Connecting Lives, Sharing Cultures

Please attach passport-sized photo

here

I. PERSONAL INFORMATION Complete name as appears in NSO birth certificate/passport: (Last / Firs t / Middle)

Birthda te: (mm/dd/yy) Gender: Male

Female

Complete home/mailing address : (House No., Street, Barangay, City/M unicipality, Province)

Region: Zip Code :

Home phone w/ area code:

Mobile phone/s:

Email/s:

Name of Fathe r/Legal Guardian (for minors):

Name of Mother/Le gal Guardian (for minors):

Job/Occupation & Em ploye r Name:

Job/Occupation & Em ploye r Name:

Work or Mobile Phone/s:

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

Passport No. (if availa ble):

Passport issue date: Passport expiry date: City /Country issu ing passport:

Religion: Christianity

Islam

Other _____________

I am allergic to: Foods I cannot eat: Native/Foreign languages spoken:

AFS Programs: I learned about AFS through

AFS returnee/alumni/voluntee r School Friends/re latives Internet Print (newspaper/brochure/poster) Other ______________________

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

Complete school/company mailing address: (House No., S treet, Barangay, City/Mun icipality, Province)

Region: Zip Code :

Complete name of school principal/administrator /immedia te supe rvisor:

Tele phone/s :

Fax: Email/s: Mobile Phone/s:

For s tudent on ly: Year Level in June 2013

For s tudent on ly: Average grade in previous school year:

For Tea cher only: PRC L icense Number For Adult only: Marital Status & No. of de pendents:

III. AFS PROGRAM SPECIFIC INFORMATION Core Program Dura tion :

I choose to go abroad on:

Year Program (YP)

Semester (SM) Program

Tri-mester (TR) Program

Intensive Program (IP)

Very Short (VS) Program

I choose to start my travel on:

January-June (SH cycle)

July-December (NH cycle)

Program Content:

High school University Community Service Class Exchange

Culture Study & Immersion Dance Mus ic Eco-Tourism Educator

English language Intensive Fore ign langua ge Community College Internship Sports

Teache r assis tant Volunteer

Other: _______________________

Preferre d AFS Patner:

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

Asia Europe

North America South America

Africa My top 3 destinations are:

1. _______________________

2. _______________________

3. _______________________

Schola rship Information :

AFS Asia and the Pacif ic Initiative

(AAI) Schola rship

Kamenori Scholarship Year Program

Kennedy -Lugar Youth Exchange & Study (YES) Program, 11 m onths

Hirosh ima City Partial Scholarship (YP)

Next 50 Scholarship (YP)

Other: _________________________

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

Program:

Pre-Application p. 2 2013

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 : (Additiona l signature of Parent/s or legal guardian is required, if applicant is a minor.)

Date of application:

(mm/dd/yy)

Date re ceived by AFS vol/staff :

SUBMIT Online Applications at: https://www.afsglobal.org/AFSGlobal/OnlineApplication