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2008 Program Leader Volunteer App

2008 Program Leader Volunteer App

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AFS Program Leader Volunteer Application
AFS Program Leader Volunteer Application

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Published by: robbhale9216 on Jan 07, 2009
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08/27/2015

2007

Program Leader
Application
Staple one photo here.
Print your name and USA on the back.
_______________________________________________________________________________________________________
CANDIDATE’S NAME LAST FIRST MIDDLE
_______ – ______ – ________
SOCIAL SECURITY NUMBER
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
CHAPTER AREA TEAM STATE
2/06
Staff Use Only
App. Rec._______
Country _______
2008
02/08
Volunteer Application
Checklist for Application Completeness — Program Leader Application
In order for your application to be complete you must submit the following forms. Incomplete or missing
information will result in a processing delay of your application and could affect your chances of being
selected for the program of preference.
All candidates must submit:
❏Three pictures (full face, individual portrait)
❏Form #1PL (Candidate Personal Information)
❏Form #1PLA - Addendum for Candidates with Dietary Restrictions
❏Form #2PL* (Essay)
❏Form #3PL* (Health Certificate)
❏Participation Agreement*
❏ Form #4PL - AFS Program Leader Reference Form
(2 originals completed by separate individuals)
❏ Applicant’s Current Resume
Please be sure to submit 2 copies of each original form in your application.
*
Signatures are required on this form.
FOR AFS USE ONLY
Received Date
❏ ————
❏ ————
❏ ————
❏ ————
❏ ————
❏ ————
❏ ————
❏ ————
02/08
1PL
Program Leader
Candidate Information
Please type or print legibly in black ink.
Full legal name, also indicate male/female (Mr/Ms):
Mr.
Ms.
LAST (FAMILY) NAME FIRST MIDDLE (NICKNAME: NAME YOU PREFER)
Address for mailing purposes:
STREET OR P.O. BOX CITY
STATE/PROVINCE ZIP/POSTAL CODE COUNTRY
Home Telephone (______) _______________________________________________Birth Date_____________________________________________________
DAY MONTH YEAR
Work Telephone: (______) _______________________________________________Best time to call _______________________________________________
Fax: (______) ___________________________________________________________E-mail: ________________________________________________________
Occupation: ___________________________________________________________Employer _____________________________________________________
For visa purposes:
Passport No. ___________________________________________________________Date of expiration _____________________________________________
CITY OF BIRTH COUNTRY OF BIRTH COUNTRY OF CITIZENSHIP COUNTRY OF LEGAL RESIDENCE
Emergency contact:
( )
LAST NAME FIRST NAME RELATIONSHIP TELEPHONE
Language proficiency (for languages other than your native language): Proficiency
Language: _______________________________Years studied ______________ Speaking ________Reading _________Writing ___________
Language: _______________________________Years studied ______________ Speaking ________Reading _________Writing ___________
Language: _______________________________Years studied ______________ Speaking ________Reading _________Writing ___________
AFS connections:
Has your family hosted on AFS? ❏ Yes ❏ No
If yes, from what country, and when: __________________________________________________________________________________________________
Have members of your family participated on an AFS program? ❏ Yes ❏ No
If yes, to what country, and when: ______________________________________________________________________________________________________
Do you have any dietary restrictions, including any which are for religious reasons or are self-imposed?
❏ Yes If yes, please explain ________________________________________________________________________________________________________
❏No ________________________________________________________________________________________________________
* If yes, complete and submit the 1G Addendum form.
Do you have any physical restrictions, impairments, or allergies that will limit placement options or participation in walking, sightseeing, or
teaching in hot weather?
❏ Yes If yes, please explain ________________________________________________________________________________________________________
❏ No ________________________________________________________________________________________________________
Can you live in a household with pets: which live indoors ❏ Yes ❏ No which live outdoors? ❏ Yes ❏ No
If no to either, please identify the animal(s) and explain:_________________________________________________________________________________
______________________________________________________________________________________________________________________________________
Have you ever been convicted of a felony? ❏ Yes ❏ No
02/06 02/08
AFS Applicant: Please complete this form if you have a dietary restriction. This form will be used to explain to the potential host country
the limits of your diet.
1. Indicate those foods that you are willing to eat:
❏ Beef ❏ Chicken ❏ Pork ❏ Fish ❏ Dairy products (e.g., eggs, milk, cheese)
2. Will you eat foods cooked or baked with or in:
❏ Beef ❏ Chicken ❏ Pork ❏ Fish ❏ Dairy products (e.g., eggs, milk, cheese)?
3. Please indicate the reason(s) for your dietary restrictions:
❏ Self imposed (this would include moral or value-based restrictions)
❏ Religious
❏ Medical (must be explained on health form 3G)
❏ Other: explain____________________________________________
4. Please read and sign at the bottom:
An AFS experience involves flexibility and an enormous amount of learning. The AFS participant is expected to adapt to
the host family’s way of living. Participants with dietar y restrictions are ver y difficult to place in some countries where it is
culturally unacceptable not to eat with the family or not to eat what is prepared and ser ved. (In many countries it is
considered inappropriate and insulting for participants to help themselves to food in the refrigerator or to prepare their
own meals.)
I und erst a nd t ha t d ue t o my d iet a ry rest ric t ions I ma y not b e p la c ed in t he c ount ry of my c hoic e. I und erst a nd t ha t my
c ount ry c hoic es ma y b e limit ed b ec a use of t his rest ric t ion a nd I will p rovid e AFS wit h a lt erna t e c ount ry c hoic es if nec essa ry.
I a lso und erst a nd t ha t t he review a nd a c c ep t a nc e p roc ess ma y t a ke long er d ue t o my d iet a ry rest ric t ions. I und erst a nd
t ha t , if a c c ep t ed t o p a rt ic ip a t e, I ma y ha ve t o wa it long er t ha n norma l t o lea rn of my host fa mily p la c ement .
CANDIDATE’S SIGNATURE _______________________________________________________
02/06
1PL Addendum
For Candidates With Dietary Restrictions
_________________________________________________________________________________________________________________________________________________________
CANDIDATE’S NAME CITY STATE/COUNTRY
02/08
2PL
Program Leader
Personal Essay
_____________________________________________________________________________________
CANDIDATE’S NAME CITY STATE/COUNTRY
1. Describe your personality, what is important to you, and your day to day activities.
2. What are your reasons for applying to this program and what do you hope to gain from it?
3. Please describe the nature of your previous and current involvement with AFS.
4. What in your personality or background would contribute to your success as a Program Leader?
Please TYPE or print legibly with black ink. If using a
word processor, please include your NAME and STATE
at the top and include the questions as well as the
answers. SUBMIT THREE COPIES.
02/06
02/08
5. How can you contribute to the participant’s experience and to you host community?
6. What experience have you had working with teenagers?
7. What international travel or cross-cultural expereinces have you had? (when, duration, and type of travel)
I certify that the foregoing information is correct. Misrepresentation of information could result in disqualification.
____________________________________________________________________________________________________________
CANDIDATE’S SIGNATURE DATE
2PL
Program Leader
Personal Essay
02/06 02/08
3PL
Program Leader Health Certificate
_______________________________________________________________________________________________________________________________________
CANDIDATE’S NAME COUNTRY BIRTHDATE
1. Height: __________ 2. Weight: __________
3. Following a general examination of the candidate, do you note any abnormalities including height, weight, blood pressure,
pulse rate, vision or hearing? ❏ yes ❏no If yes, attach a written report.
4. a) Check Yes or No for any condition the candidate has had. If Yes, give detailed information and dates below.
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
4. b) Give detailed information and dates concerning any medical impairment or disability not identified above.
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
5. Give dates, diagnosis and outcome of each accident, illness or operation requiring hospitalization.
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
6. Does the candidate have any allergies? ❏ yes ❏ no If yes, please identify type, any medication taken, name, dosage
and frequency.
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
7. Is the candidate currently taking any medication or injections (other than those mentioned previously)? ❏ yes ❏ no
If yes, identify the medication, reason for usage, dosage and frequency.
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
8. Does the candidate have any condition, impairments or limitations which would restrict participation in physical activities?
❏ yes ❏ no If yes, attach a written medical report.
9. Has the candidate ever been evaluated for a neurological or emotional condition, including any eating disorders?
❏ yes ❏ no If yes, attach in a sealed envelope: 1) a full report by the clinician and 2) a statement by the candidate
about
the illness or specific problem.
10. Give your opinion of the general state of the candidate's health: ❏ excellent ❏ good ❏ fair ❏ poor
11. Indicate the dates the candidate had the following vaccinations:
Day/Mo/Yr Day/Mo/Yr Day/Mo/Yr Day/Mo/Yr Day/Mo/Yr Day/Mo/Yr
Measles _______________ Poliomyelitis ______________ ______________ ______________ ______________ ______________
Mumps _______________ Diphtheria ______________ ______________ ______________ ______________ ______________
Rubella _______________ Pertussis ______________ ______________ ______________ ______________ ______________
Tetanus ______________ ______________ ______________ ______________ ______________
12. Candidate has been my patient for ________ years.
I, the undersigned, have given a thorough physical examination and reviewed the medical history of the candidate and certify that all important
medical information has been included and that nothing relevant has been omitted.
PRACTITIONER'S NAME (PRINT OR TYPE) DEGREE ADDRESS
SIGNATURE DATE
Your signature below attests that the information on Form3PL is correct and complete.
CANDIDATE'S SIGNATURE DATE
To be completed by the candidate's examining practitioner, and also
signed by the candidate. Every question must be answered in full.
Yes No
Chicken Pox ❏ ❏
Measles ❏ ❏
Poliomyelitis ❏ ❏
Rheumatic Fever ❏ ❏
02/06
Yes No
Rubella ❏ ❏
Asthma ❏ ❏
Diabetes ❏ ❏
Hepatitis ❏ ❏
Yes No
Headache (persistent, recurring) ❏ ❏
Learning or Speech Defect ❏ ❏
Seizure Disorder ❏ ❏
Tuberculosis ❏ ❏
02/08
4PL AFS Program Leader
Reference
_______________________________________________________________________________________________________________________________________
CANDIDATE’S NAME CITY STATE/COUNTRY
AFS Program Leaders will be responsible for the welfare of a group of up to 30 teenagers in a foreign country for 2-4 weeks. Their role is to
lead and support their group during the normal adjustments to living and learning in a different country. They are also responsible for han-
dling any emergency or crisis that might arise during the program.
1. How long have you known the candidate and in what capacity?
2. Assess and describe the candidate’s motivation and expectations of the program. (Most programs involve living conditions which
will be very basic and rustic. Traditional comforts will not be available.)
3. Please provide any observations of the candidate in a group setting and his/her relationship with others in a group.
4. Please describe the personal and professional strengths the candidate will bring to the program and group experience
(include comments on self-confidence, interaction with others, leadership ability, flexibility, tolerance, and empathy).
5. How well does the candidate react to sudden change in schedule, emergencies, and awkward situations?
6. I recommend this candidate for the AFS Global Educator
❏ very highly ❏ highly ❏ with reservation
Please explain reservations.
WRITER’S NAME HOME PHONE WORK PHONE
WRITER’S SIGNATURE DATE RELATIONSHIP TO CANDIDATE
02/06
02/08
Program Leader
Participation Agreement
Fees
AFS-USA Covers: The Program Leader’s participation fee, which includes lodging, meals,
return domestic and international travel and on-program transportation.
Program Leader Covers: Incidental expenses, visa and passport fees and any
necessary inoculations.
Prior to departure the Program Leader will be provided an advance to cover program-related
expenses. Upon his or her return, the Program Leader will submit an expense report with
accompanying receipts and balance of the advance.
The Program Leader is not an employee of AFS-USA and undertakes this assignment
on a voluntary basis.
By signing the below I certify that I understand the terms as outlined above.
_____________________________________________________________________________
CANDIDATE’S NAME (Please print)
_____________________________________________________________________________
CANDIDATE’S SIGNATURE
02/06
02/08
Program and Country Preferences
Please indicate your program preferences below. If you choose more than one program,
please number your choices in order of priority. Please note, the travel dates are tentative
and begin with the date that you are required to arrive at the point of international
departure in order to act as a group leader during the overnight, gateway orienation.
Type Country Tentative ProgramDates Preference
Outdoor Adventure Australia 6/27 - 8/20 ________________________
Language Study China 7/1 - 8/15 ________________________
Community Service Costa Rice 6/22 - 7/31 ________________________
Team MIssion Ghana 6/27 - 7/31 ________________________
Language Study Spain 6/28 - 8/4 ________________________
*Program availability and dates to be confirmed.
02/06
02/08
Program Program Dates Preferences
Australia - Outdoor Adventure 6/27 - 8/20 __________________
China - Language Study 7/1 - 8/15 __________________
Costa Rica - Community Service 6/22 - 7/22 __________________
France - Language Study 6/26 - 7/30 __________________
Ghana - Team Mission 6/27 - 7/31 ___________________
*Program availability and dates to be confirmed.




























RETURN COMPLETED APPLICATION TO:

Office of Volunteer Development
AFS-USA
231 East Baltimore Street, 15
th
Floor
Baltimore, MD 21202

FAX: 503.961.8383
Email: Vol.reg@afs.org
ref line: Program Leader

www.usa.afs.org
AFS-USA Mission Statement
AFS-USA works toward a more just and peaceful world by
providing international and intercultural learning
experiences to individuals, families, schools and
communities through a global volunteer partnership.

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