Student

YOUTH APPLICATION PACKET: For Summer 2013

YOUTH AMBASSADORS PROGRAM WITH CANADA
Organized by Center for the Study of Canada, SUNY Plattsburgh with Support from the Bureau of Educational and Cultural Affairs, United States Department of State, The United States Embassy Ottawa & Fulbright Canada

PROGRAM DESCRIPTION
The Youth Ambassadors Program with Canada is a three week exchange designed for Canadians to go to the U.S.A. Conducted in the English language, the program brings together high school students and adult mentors from Canada to promote mutual understanding, increase leadership skills, and prepare youth to make a difference in their communities. Program themes include: civic education, community service, youth leadership development and entrepreneurship. The program employs a highly interactive approach both in workshops and in a range of public and community settings plus home stays with American families. Through engagement with leaders of community, public, and private entities in program locations, student and adult Youth Ambassador Participants will better understand civic participation and the rights and responsibilities of citizens in a democracy. Upon their return home, Youth Ambassadors will work to apply what they learned to implement community service projects that serve needs in their own communities and be engaged through alumni network initiatives. The Youth Ambassadors Program with Canada is an intensive program with three segments: 1) Pre-departure orientation in Ottawa, Ontario, Canada to take place July 8-9, 2013 2) Exchange experience in the United States of America to include: a) Plattsburgh, New York and the Adirondack Park from July 10 to 21, 2013 b) Hyde Park and New York City, New York from July 22 to 23, 2013 c) Washington, D.C. from July 24 to 28, 2013 3) Follow-on community service activities in Canada to be implemented following the exchange experience. As an integral element of the exchange program, Youth Ambassadors will also plan and implement a variety of incountry educational activities upon their return to Canada. The Youth Ambassadors Program with Canada delivers an exceptional content-rich educational opportunity – an opportunity that will result in significantly deeper knowledge and appreciation by Youth Ambassadors of citizen-engaged participatory democracy in the United States, the value of community service activities, and the necessary leadership skills required to successfully undertake important entrepreneurial project initiatives. Travel, meal and accommodation costs associated with exchange participation from July 8-28 are to be covered by the program. Participants will be responsible for some personal costs such as passport application fees and personal spending money. While participants will have health care benefits during the exchange in the U.S., covered medical expenses are subject to limitation, and pre-existing conditions are not covered; participants will also be responsible for the $15 co-pay required for each doctor’s office visit in the U.S. Application Deadline and Participant Selection Timeline: April 20, 2013. Interviews for highly qualified applicants will take place at the end of April 2013. Notification of selected participant acceptance will be issued in May.
1 This application is free of charge and may be duplicated.

YOUTH APPLICATION PACKET: For Summer 2013

APPLICANT ELIGIBILITY AND CRITERIA SELECTION
The program sponsors seek energetic applicants who are ready to develop their skills in order to be effective leaders in their schools and communities. Applicants must demonstrate the motivation and commitment to be an active, engaged Youth Ambassador. Applicants are to present a clearly demonstrated interest about the United States, the three themes (civic education, community service, youth leadership development) and sub-theme (entrepreneurship) of the exchange program. Youth and adults with Canadian citizenship only are eligible to apply; dual U.S. citizens are not eligible. Applicants must have fluent English language skills. Preference will be given to applicants who have not had previous experience studying or traveling in the United States. The group of selected participants must represent the diversity of Canada – geographic, ethnic, socio-economic, new Canadians (first generation Canadians and Canadians born outside Canada), First Nations, multi-generational Canadians, and gender balance. Preference will be given to those student applicants in particular who are recent immigrants, new Canadians or from aboriginal populations. In addition, as participation in previous Youth Ambassador programs was heavily weighted towards those from B.C., Calgary and the Greater Toronto Area, applicants from other than those locations will receive preference in the 2013 program. Note that a criminal background check is required for all participants. Applications are invited from secondary school students. Students must be between 15 and 18 years old at the start of the actual program on July 8, 2013. To be accepted for the program, youth will have at least one semester (a minimum of 4 months) remaining of secondary school after participation in the exchange. Permission for youth participation must be granted from both parents/legal guardians and schools. Youth applicants will be evaluated on the following characteristics: A demonstrated interest in and commitment to volunteer and participate in civic activities Leadership potential Good social and communication skills Good academic performance Ability to implement activities that benefit the applicant’s school and/or community Ability to represent the diversity of Canada Applications are also invited from adults who are active as secondary teachers, trainers, school administrators, and/or community leaders who work with teen-aged youth. Adults accepted for the program will demonstrate a commitment to supporting teenage youth and to facilitating the youth participants of the exchange program to become productive and responsible members of society by serving as a key member of the post-exchange mentoring experience. Adult applicants will be evaluated on the following characteristics: A demonstrated interest in and commitment to volunteer and participate in civic activities Demonstrated history of supporting youth activities Strong record in teaching and/or youth program involvement Demonstrated leadership The selection of high school youth and adult educators applying for the Youth Ambassadors Program Canada will be merit-based. All selected participants are expected to be willing and available to periodically meet with fellow program participants during the 2013-2014 academic year to support follow-on work after the exchange experience.
2 This application is free of charge and may be duplicated.

YOUTH APPLICATION PACKET: For Summer 2013

YOUTH AMBASSADORS PROGRAM WITH CANADA
Organized by Center for the Study of Canada, SUNY Plattsburgh with Support from the Bureau of Educational and Cultural Affairs, United States Department of State, The United States Embassy Ottawa & Fulbright Canada

APPLICATION DEADLINE: APRIL 20, 2013
Please fill out this application as completely as possible in English. The information you provide on this application will serve as the basis for selecting semi-finalists for this program. Answer the questions carefully and completely. Before completing this application, applicants should thoroughly read the “Program Description, Applicant Eligibility and Criteria Selection” to ensure they meet the eligibility criteria. There is no fee to apply. ONLY COMPLETED APPLICATIONS WILL BE REVIEWED. Questions regarding the application and selection process should be addressed to Dr. Christopher Kirkey, Director, Center for the Study of Canada, State University of New York (SUNY) College at Plattsburgh, 133 Court Street, Plattsburgh, NY 12901 USA; E-mail: [e-mail]; Tel: [phone]; Fax: [phone]. Applications are to be submitted by April 20, 2013 to Ms. Patricia Latendresse, Fulbright Canada, 350 Albert Street, Suite 2015, Ottawa, ON, Canada K1R 1A4; E-mail: [e-mail]; Tel: [phone]; Fax: [phone].

APPLICATION
Legal Name ___________________________________________________________________________
Last (Family) Name First Name Middle Name

(Enter name exactly as it appears on official documents.) Preferred Name (if not First Name) _____________________________ Sex (Check one) Male ___ Female ___ Date of Birth ______/______/___________
Day Month Year

Age you will be as of July 2013 ____________________

Permanent Home Address _______________________________________________________________
Number & Street City, Province/Territory Postal Code Apt. Number

_____________________________________________________________________________________ Telephone Home _______________________________ Cell/Other ______________________________ Preferred Telephone (Check One) Home ___ Cell/Other ___ Email ________________________________________________________________________________
Current mailing address for program correspondence, if different from above. From _____________ To _____________
Date Date

_____________________________________________________________________________________
Number & Street

_____________________________________________________________________________________
City, Province or Territory Postal Code

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This application is free of charge and may be duplicated.

YOUTH APPLICATION PACKET: For Summer 2013
If current address is a school, write school name _____________________________________________ City and Country of Birth ________________________________ Number of Years Living in Canada ____ Country of Citizenship or permanent legal residence __________________________________________ Do you have a valid passport? Yes ___ No ___ If yes, Issuing Country _____________________________ Passport Number _____________________________ Expiration Date ____________________________ Have you lived and/or studied in the United States or in another country? Yes ___ No ___ If yes, where and when:

First Language ___________________________________ Additional Language Proficiency:
Language (write name of language and check all that apply) Speak Write Read Spoken at Home Number of Years

Ethnic Origin (categories taken from the Canadian census; please check all that apply) ___White/Caucasian ___Black / African ___Chinese ___South Asian (e.g., East Indian, Pakistani, Sri Lankan, etc.) ___Filipino ___Hispanic / Latino ___Arab ___Southeast Asian (e.g., Vietnamese, Cambodian, Malaysian, Laotian, etc.) ___Korean ___Japanese ___Pacific Islander ___West Asian (e.g., Iranian, Afghan, etc.) Aboriginal Person (Status or Non-Status Indian) ___First Nations/North American Indian ___Métis ___Inuk ___Other – Specify:

Secondary School Name __________________________________________ Current Level ___________ Principal’s Name _______________________________ Entry Date _______ Expected Graduation _____
Date Date

School Address_________________________________________________________________________
Number & Street Apt. Number ____________________________________________________________________________________________________ City, Province/Territory Postal Code

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This application is free of charge and may be duplicated.

YOUTH APPLICATION PACKET: For Summer 2013
School Type: ___Public ___Private ___Religious ___Home School ___Other

List all other secondary schools, academic summer schools, enrichment programs and/or university courses you have attended:
School/Program/Course Name Location (City, Province/Territory) Dates Attended (month/year)

_____________________________________ _____________________________________ _____________________________________ List all courses taken in last two academic years:

______________________ ______________________ ______________________

___________________ ___________________ ___________________

Describe your academic interests/coursework you enjoy studying:

Describe any honors or special recognition you have received, for what, and when:

Describe activities (extracurricular, community, hobbies, clubs, work, etc.) in which you participate, and how long you have been involved with each?

Describe your career interest(s):

Do you have a part time job? Yes ____ No ____ If yes, describe:

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This application is free of charge and may be duplicated.

YOUTH APPLICATION PACKET: For Summer 2013

INFORMATION COLLECTED ON THIS PAGE IS FOR THE PURPOSE OF HOME STAY PLACEMENT IN PLATTSBURGH, NY, USA
Dietary restrictions or preferences, if any ___________________________________________________
(For example, vegetarian, no pork, kosher, halal, no shellfish, etc.)

List allergies, if any _____________________________________________________________________
(For example, allergic to pollen, shellfish, peanuts, cats, dust, etc.)

Do you have any physical limitations or medical conditions we should be aware of? Yes ___ No ___ If yes, describe: _____________________________________________________________________________________
(For example, hard of hearing)

Religious preference, if any ______________________________________________________________ How would you like to observe your religion while you are in the United States? We will do our best to accommodate your wishes. ___ I do not want ___ I want to practice my religion in the United States. Choose one option below: ___ I am curious to see religious services of my faith in the United States to observe a ___ I would like the opportunity to pray or attend services regularly religion while in ___ It is very important to me to have the opportunity to pray or attend services regularly the United States Please specify which services you would like to attend and when: If your host family attends religious services, they will invite you to join them. This is a good cultural exchange opportunity. Are you interested in doing this if the opportunity arises? Yes ___ No ___ Who lives in your household (parents, siblings, extended family, pets, others)?

How often do you perform chores at home (clean dishes/floors, help with cooking, babysit, take out the garbage, etc.) or help out around the house. ___ Often ___ Sometimes ___ Rarely ___ Never If you do help with household chores, what chores do you like to do?

Many American families have pets living in their homes. Please indicate whether you would be comfortable living in the following situations (check all that apply).
___ The dogs have free roam of the house ___ The dogs are kept outside ___ Cats are kept in the house ___ The dogs are in the house, but kept out of my bedroom ___ The dogs are kept in a specific room of the house when allowed inside ___ There are no dogs on my host family’s property

Do you smoke? Yes ____ No ____ Do you have access to high speed internet? Yes ___ No ___ If yes, describe where and how frequently do you use the internet.

Do you use social networking sites? Yes ___ No ___ If yes, which one(s) __________________________
6 This application is free of charge and may be duplicated.

YOUTH APPLICATION PACKET: For Summer 2013
SHORT ESSAY QUESTIONS: PLEASE WRITE OR TYPE YOUR ANSWERS TO THE FOLLOWING MANDATORY QUESTIONS ON SEPARATE PAGES AND ATTACH TO YOUR APPLICATION. EACH ANSWER SHOULD BE NO MORE THAN A HALF PAGE IN LENGTH, TO TOTAL NO MORE THAN TWO PAGES FOR ALL ANSWERS TO THE SHORT ESSAY QUESTIONS. A. Why is participation in this program important to you and/or your community? B. During this exchange, participants will act as ambassadors for their countries. How will you fulfill this role? What qualities does a good ambassador exhibit? C. What has helped you become an effective leader? What leadership skills would you like to improve? D. Identify a specific issue or problem affecting your school, neighborhood, or community. What might you do to help improve this issue or problem? E. Is there anything else you would like to share about yourself? REFERENCES: THREE MANADATORY REFERENCES ARE REQUIRED FOR EACH YOUTH APPLICANT. THREE REFERENCE FORMS ARE PROVIDED AS PART OF THIS APPLICATION PACKAGE FOR THIS PURPOSE. REFERENCES ARE TO BE PROVIDED BY ADULTS, SUCH AS TEACHERS OR OTHER ADULTS WHO KNOW YOU WELL BUT WHO ARE NOT FAMILY MEMBERS. SIGNATURE OF APPLICANT With the submission of this application, I certify that all information provided is true. _________________________________________________________
Applicant Signature

Date ___________________
Day/Month/Year

SIGNATURE OF PARENT/GUARDIAN I permit my son/daughter to apply for and, if selected, to participate in this program. _________________________________________________________
Parent/Guardian Signature

Date ___________________
Day/Month/Year

Printed Name of Parent/Guardian: _______________________________________________________ Parent/Guardian Contact Information Name _____________________________ Telephone _________________________________________
Day Evening

Name _____________________________ Telephone _________________________________________
Day Evening

Email Address(es) ______________________________________________________________________ Mailing Address (if different from applicant’s permanent mailing address) _____________________________________________________________________________________
Number & Street

______________________________________________________________________________________________________________________ City, Province or Territory Postal Code

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This application is free of charge and may be duplicated.

YOUTH APPLICATION PACKET: For Summer 2013

YOUTH AMBASSADORS PROGRAM WITH CANADA
Organized by Center for the Study of Canada, SUNY Plattsburgh with Support from the Bureau of Educational and Cultural Affairs, United States Department of State, The United States Embassy Ottawa & Fulbright Canada

REFERENCE
APPLICANT INSTRUCTIONS: Below, fill in your name and give this form to a teacher or other adult outside of your family who knows you well. The reference to be provided by this person is to be completed in English. Ask the reference to fill out the form and return it to you. Once you have the application completed, send all materials by April 20, 2013 to Ms. Patricia Latendresse, Fulbright Canada, 350 Albert Street, Suite 2015, Ottawa, ON, Canada K1R 1A4; E-mail: [e-mail]; Tel: [phone]; Fax: [phone].

APPLICANT NAME ______________________________________________________________________ FOR THE REFERENCE: This program is an exchange program involving a three-week trip to the United States, a challenging academic environment, and intensive leadership training. To succeed, participants must be highly motivated, and able to adjust to living and working with people of different social and cultural backgrounds. Please be honest in your assessment of the applicant to help us select the most appropriate participants. If you would like to add additional comments, we encourage you to do so. Your recommendation will be evaluated along with the student’s own application. Please indicate your opinion of this applicant’s ability to meet the challenges of this program. Check one: ___ I strongly recommend this applicant ___ I have minor reservations about recommending this applicant ___ I recommend this applicant ___ I have major reservations about recommending this applicant

How long, and in what context, have you known this applicant?

What are the applicant’s strengths and weaknesses?

Please describe the applicant’s behavior with respect to authority, peer relationships, and activities as best you are able.

Do you think the applicant would adapt well to unfamiliar environments and new situations? Why or why not?

Name (printed) ________________________________________________________________________ _________________________________________________________ Date ___________________
Signature

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This application is free of charge and may be duplicated.

YOUTH APPLICATION PACKET: For Summer 2013

YOUTH AMBASSADORS PROGRAM WITH CANADA
Organized by Center for the Study of Canada, SUNY Plattsburgh with Support from the Bureau of Educational and Cultural Affairs, United States Department of State, The United States Embassy Ottawa & Fulbright Canada

REFERENCE
APPLICANT INSTRUCTIONS: Below, fill in your name and give this form to a teacher or other adult outside of your family who knows you well. The reference to be provided by this person is to be completed in English. Ask the reference to fill out the form and return it to you. Once you have the application completed, send all materials by April 20, 2013 to Ms. Patricia Latendresse, Fulbright Canada, 350 Albert Street, Suite 2015, Ottawa, ON, Canada K1R 1A4; E-mail: [e-mail]; Tel: [phone]; Fax: [phone].

APPLICANT NAME ______________________________________________________________________ FOR THE REFERENCE: This program is an exchange program involving a three-week trip to the United States, a challenging academic environment, and intensive leadership training. To succeed, participants must be highly motivated, and able to adjust to living and working with people of different social and cultural backgrounds. Please be honest in your assessment of the applicant to help us select the most appropriate participants. If you would like to add additional comments, we encourage you to do so. Your recommendation will be evaluated along with the student’s own application. Please indicate your opinion of this applicant’s ability to meet the challenges of this program. Check one: ___ I strongly recommend this applicant ___ I have minor reservations about recommending this applicant ___ I recommend this applicant ___ I have major reservations about recommending this applicant

How long, and in what context, have you known this applicant?

What are the applicant’s strengths and weaknesses?

Please describe the applicant’s behavior with respect to authority, peer relationships, and activities as best you are able.

Do you think the applicant would adapt well to unfamiliar environments and new situations? Why or why not?

Name (printed) ________________________________________________________________________ _________________________________________________________ Date ___________________
Signature

9

This application is free of charge and may be duplicated.

YOUTH APPLICATION PACKET: For Summer 2013

YOUTH AMBASSADORS PROGRAM WITH CANADA
Organized by Center for the Study of Canada, SUNY Plattsburgh with Support from the Bureau of Educational and Cultural Affairs, United States Department of State, The United States Embassy Ottawa & Fulbright Canada

REFERENCE
APPLICANT INSTRUCTIONS: Below, fill in your name and give this form to a teacher or other adult outside of your family who knows you well. The reference to be provided by this person is to be completed in English. Ask the reference to fill out the form and return it to you. Once you have the application completed, send all materials by April 20, 2013 to Ms. Patricia Latendresse, Fulbright Canada, 350 Albert Street, Suite 2015, Ottawa, ON, Canada K1R 1A4; E-mail: [e-mail]; Tel: [phone]; Fax: [phone].

APPLICANT NAME ______________________________________________________________________ FOR THE REFERENCE: This program is an exchange program involving a three-week trip to the United States, a challenging academic environment, and intensive leadership training. To succeed, participants must be highly motivated, and able to adjust to living and working with people of different social and cultural backgrounds. Please be honest in your assessment of the applicant to help us select the most appropriate participants. If you would like to add additional comments, we encourage you to do so. Your recommendation will be evaluated along with the student’s own application. Please indicate your opinion of this applicant’s ability to meet the challenges of this program. Check one: ___ I strongly recommend this applicant ___ I have minor reservations about recommending this applicant ___ I recommend this applicant ___ I have major reservations about recommending this applicant

How long, and in what context, have you known this applicant?

What are the applicant’s strengths and weaknesses?

Please describe the applicant’s behavior with respect to authority, peer relationships, and activities as best you are able.

Do you think the applicant would adapt well to unfamiliar environments and new situations? Why or why not?

Name (printed) ________________________________________________________________________ _________________________________________________________ Date ___________________
Signature

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This application is free of charge and may be duplicated.