BOLDLEADERS YOUTH AMBASSADOR PROGRAM 2013/2014 APPLICATION FORM

Dear Youth Leader, The BoldLeaders Youth Ambassador Program funded by the United States Department of State and overseen locally by the US Embassy of Trinidad and Tobago invites youth 15-18 years to apply for the 2013 and 2014 program. A life changing experience and a lifetime of service begins with a one month exchange to the United States. The exchange allows youth to: Develop and understand their basic human resources Participate in skills-based trainings Engage with local government & organizations Interact with their peers from other countries Experience different cultures and norms Travel Dates: October 2013 February 2014 What are the Requirements? Enrolled in secondary school Between the ages of 15 and 18 Outstanding school record From family with limited economic means Display leadership qualities Demonstrated interest in improving local community Please note: Students turning 15 on or before the 1st of October 2013 or the 1st of February 2014 can apply Students turning 19 on or before the 30th of October or the 28th of February cannot apply.

Applications Guidelines: Completed applications must be submitted by midnight April 7th 2013 to ttyouthambassadors@gmail.com with the Subject: NAME BLYA APPLICATION e.g JANE DOE - BLYA APPLICATION We look forward to receiving your application. Regards, Youth Ambassadors Team
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BOLDLEADERS YOUTH AMBASSADOR PROGRAM 2013/2014 APPLICATION FORM

Instructions: Carefully read the requirements for this program and legibly complete this form Applicant Information

First Name

Middle Name

Family Name

Home Address

Male Female

Age

Date of Birth (Mo/Day/Yr)

Country of Birth

Home Telephone Family Information: Parent/Guardian Fathers Name

Mobile Number

E-Mail Address

Occupation

Name of Company

Home Address

Business Numbers Mothers Name

Cell Number

E-Mail Address

Occupation

Name of Company

Home Address

Business Number

Cell Number

E-Mail Address

Education: Present School

School Name

Address

Form Teacher Name

Contact Number

BOLDLEADERS YOUTH AMBASSADOR PROGRAM 2013/2014 APPLICATION FORM

CXC Qualification (Subjects & Grades )

If you have not sat CXC, list subjects you are presently pursuing and your last terms grades

List other Qualification / Certification

Why are you the most suitable candidate for the BoldLeaders Youth Ambassadors Program 2013/2014?

BOLDLEADERS YOUTH AMBASSADOR PROGRAM 2013/2014 APPLICATION FORM

In keeping with our theme, I am Bold Rising Beyond Challenges, not exceeding 400 words state what has been your greatest challenge in life to date?

State how you have or intend to contribute to your community/country?

BOLDLEADERS YOUTH AMBASSADOR PROGRAM 2013/2014 APPLICATION FORM

Are you involved in any 1) school activities 2) community activities 3) sporting activities 4) religious groups? Yes No If yes please state which ones and exactly how you contribute:

Have you ever travelled to the United States of America? Yes No If yes, please state the last time and the purpose of your visit

Do you have any immediate family residing in the United States of America? Yes No If yes, please state name (s), their relationship to you and the state they reside in?

Please provide your Reference Contact Details: (Someone who can elaborate on your character eg. a teacher, a pastor, a coach) Name: Address: Relationship to you: Contact Numbers: Email address:

BOLDLEADERS YOUTH AMBASSADOR PROGRAM 2013/2014 APPLICATION FORM

I acknowledge that the information presented above is a true representation of the applicant. I also acknowledge that if selected further background checks will be done and if any discrepancies are found this will automatically forfeit my child/ward ability to participate in the Youth Ambassadors Program.

Parent/ Guardian

Applicant

Date

Date