Candidate Application

AT TA CH PHOTO HERE

Elijah Daniel (Ms.)(Mr.) First name Puerto Princesa Home city

Batislaong Middle name Palawan Home state/province

Geanga Last name Philippines Home country

27 May 1996 Birthdate: day/month(spell word)/year PHI AFS sending organization

For office use only
AFS ID# Program applying for

1 Basic Personal Information
1 CANDIDATES LEGAL NAME

FOR OFFICE USE

AFS ID#

2

ADDRESS FOR MAILING PURPOSES Street/P.O. Box Telephone

Elijah Daniel (Ms.)(Mr.) First name

Batislaong Middle name

Geanga Last name

Elijah Preferred name/nickname
Zip/Postal Code Country
5300

105 Sunflower St., WESCOM Rd., Brgy. San Miguel
Puerto Princesa City, Palawan,

City & State/Province

Philippines

3

Fax FOR VISA PURPOSES

Mobile Phone +63 (949) 668 6300 Email address

elijahdaniel.pps@gmail.com
May

Birthdate: day 27 month (spell word) Country of Birth
Philippines

year

1996

City of Birth

Iloilo City
Philippines

Country of Citizenship

Country of Legal Residence Passport Issue Date Passport Expiration Date

Philippines

Passport Number (if known) Have you ever traveled to the United States on a F-1 or J-1 Visa? and name of the sponsoring institution. 4 INFORMATION ABOUT THE PEOPLE WITH WHOM I LIVE x Father  x Mother  Stepfather  Stepmother I live with:  Place/Office of Passport Issue

x No (If yes, please indicate wich type of visa and Yes 

5

Who is your custodial parent? Please circle. (If more than one, circle both). For Adult Programs - Additional options:  Spouse  Independent  Other INFORMATION ABOUT PARENT (S)/GUARDIAN(S) WITH WHOM I LIVE x Female Parent/Guardian  Male  Legal name: First Name
April 29, 1954

Guardian Other than Parent

Elizabeth

Date of Birth Country of Birth x Male  Female Parent/Guardian  Legal name: First Name
June 25, 1950
Ephraim Joel

Philippines

Last Name

Geanga

Occupation

Teacher

Business and/or Mobile Phone Employer
+63 (905) 918 7537
DepEd

+63 (947) 775 8594

geangaelizabeth@gmail.com

Email

6

Date of Birth Country of Birth Occupation Employer CONTACT DETAILS OF ANY NATURAL PARENT WITH WHOM I DO NOT LIVE Legal name: First Name Date of Birth Last Name Occupation

Philippines

Last Name

Geanga

Farmer

Business and/or Mobile Phone Email

Business and/or Mobile Phone Employer Email

Country of Birth

7

Address EMERGENCY CONTAC T If your Parent/Guardian cannot be reached, please indicate someone else in your community whom we can contact:
Emmanuel Joy Geanga Uncle +63 (907) 213 3452

8

First Name Last Name Relationship NAMES AND BIRTHDATES OF BROTHERS AND SISTERS
N/A

Telephone Numbers (home, work, mobile)

9

AFS CONNECTIONS Has your family: (If yes, please describe who, the relationship, where and when.) x Yes  No Hosted on AFS?  x No Participated on an AFS program?  Yes  x No Any close friends or relatives living abroad?  Yes  Have you participated in any other exchange program, traveled abroad or lived in another country? Please provide details.

Updated Aug 2008

2 Placement Information
1 CANDIDATE NAME
Elijah Daniel Batislaong Geanga

FOR OFFICE USE

AFS ID#

Elijah

(Ms.) (Mr.) First name

Middle name

Last name

Home country

2

MEDICAL REQUIREMENTS AND HEALTH RESTRICTIONS
Do you have physical restrictions, impairments or allergies that will limit placement options or participation in everyday x No If yes, please explain: family and/or school activities?  Yes 

Please check the appropriate boxes if you CANNOT live with: Cats  Indoors?  Outdoors? Dogs  Indoors?  Outdoors? Other pets  Indoors?  Outdoors? If you checked boxes for other pets, please explain: If you have checked that you CANNOT live with a pet, please indicate why:
 

Allergy

Fear

Religion

Other(explain)

3

DIETARY REQUIREMENTS
Do you have dietary restrictions, including for medical, religious or self-imposed reasons? If yes, please explain: If you are a vegetarian, are you willing to eat:  Fish  Poultry  Dairy products Yes
 x

No

4

RELIGION
What is your religious affiliation, if any? (Optional)
Jehovah's Witnesses

x Weekly  Monthly  Occasionally  Never How often do you participate in structured religious services?  Bearing in mind that it is likely your host family will have different religious affiliation, how strongly do you feel about x Not necessary having access to structured religious services of your own faith?  Required 

5

SMOKI NG
x No Do you smoke cigarettes?  Yes  In some cultures it is more difficult to find placements for cigarette smokers. Given this, smokers should please choose one of the following:  I will /  I will not smoke during my AFS exchange program

6

LANGUAGES
Native language Tagalog Language proficiency (for languages other than your native language): Language Language Language
English

Years studied Years studied Years studied

12

Speaking ability:  Poor
x Poor Speaking ability: 

  

Fair Fair Fair

  

x Excellent Good 

German

1

Good Good

 

Excellent Excellent

Speaking ability:  Poor

DISCLAIMER
I understand that host countries may not be able to accommodate the restrictions or requirements indicated in the completed application and that acceptance on the AFS program is not a guarantee that these preferences can be honored. I further understand that I may not be eligible to participate in athletic teams related to my host school or community.

Candidate Signature

Date

Parent/Guardian Signature Date (Parent/Guardian signature is required for all secondary school programs and candidates not of legal age in country of residence.)
Updated Aug 2008

3a Health Certificate

FOR OFFICE USE

AFS ID#

To be completed and signed by the candidate’s physician. The physician should not be related to the candidate. Each question must be answered with a detailed explanation included or attached in a separate report for “YES” responses to questions 3-9, 11-13. AFS reserves the right to ask for further information and determine if the candidate meets the program medical qualifications. The candidate and parent/guardian must also sign.
Elijah Daniel Batislaong Geanga Philippines 27 May 1996

(Ms.) (Mr.) Candidate Name (First/Middle/Last) 1 2 Height Weight B/P Pulse

Home Country Respiration

Birthdate Blood Type

Do you note any abnormalities concerning height, weight (including substantial loss or gain in the past six months), blood pressure, pulse or respiration?  Yes  No If yes, explain

3 CHECK YES OR NO. HAS THE CANDIDATE HAD THE DISEASES / CONDITIONS LISTED BELOW:
a) Measles b) Mumps c) Rubella d) e) f) g)
YES
      

NO
      

Titer: Titer: Titer:

IF KNOWN:

Date: Date: Date:

h) Rheumatic Fever i) j)

YES
      

NO
      

If yes, give detailed information and dates (use extra pages if necessary):

Chicken Pox Poliomyelitis Hepatitis Tuberculosis

If yes, month/year:

k) l) m) n)

Cough (persistent, recurring) Headaches (persistent, recurring) Sleepwalking Enuresis Appendicitis Parasites (internal)

4 5 6 7 8 9

ACNE

Yes

No No No No No

If yes, identify area, severity, any medication taken, name, dosage & frequency: If yes, identify type, any medication taken, name dosage & frequency: If yes, identify type, severity, any medication taken, name, dosage & frequency: If yes, identify type, severity, any medication taken, name, dosage & frequency: If yes, identify type, severity, any medication taken, name, dosage & frequency:

ALLERGIES  Yes

ASTHM A

Yes

DIABETES  Yes
 Yes SEIZURE DISORDER

HAS THE CANDIDATE EVER HAD ANY DISEASE, IMP AIRMENT OR ABNORMALI TY OF:
 a) Abdominal organs, digestive system  b) Lungs, respiratory system  c) Bones, joints, locomotor system  d) Genito-urinary system If yes, please explain (use extra pages, if necessary )

YES

NO
   

e) f) g) h)

Heart blood vessels Tonsils nose or throat Blood, endocrine system Eyes/vision, ear/hearing

YES
   

NO
   

10 HAS THE CANDIDATE BEEN HOSPITALIZED?

Yes

No If yes, give dates, diagnosis and outcome for each incident.

Updated Aug 2008

3b Health Certificate
Elijah Daniel Batislaong Geanga
Candidate Name (First/Middle/Last)

FOR OFFICE USE

AFS ID#
Philippines
Home Country Yes No

11 Is the candidate currently taking medication or injections (other than those mentioned previously)? If yes, identify the medication, reason for usage, dosage and frequency:

12 Has the candidate EVER consulted a neurologist, psychologist or any other specialist for a nervous, emotional or eating disorder? Yes No 13 Is there a history of, or present evidence of, an emotional, nervous or eating disorder? Yes No If yes to either (12 or 13), a FULL report by the specialist and a statement by the candidate about the illness or specific problem must be attached in a sealed envelope. Note: Placement in a foreign host family, school and community requires adjustment which often involves emotional stress. It will not be a time for relaxation or temporary relief from any current therapy. If the candidate is experiencing current emotional, physical, personal or family difficulties, these difficulties can be severely exacerbated by the adjustment demands of the AFS program. Therefore, you are requested to evaluate carefully the candidate’s current or previous condition and treatment along with his or her ability to manage potential adjustment anxieties and stress in a foreign environment. 14 Are there any health limitations or restrictions on the candidate’s activities and / or sports participation or any medical information which should be considered for a home/school placement? Yes No If yes, please describe: 15 Does the candidate wear glasses or contact lenses? Does the candidate wear dental braces? Yes No Yes No Frequency? Yes No

16 What was the date of the candidate’s last dental check up? If yes, will orthodontic care be needed while on the program?

17 CANDIDATE HAS HAD THE FOLLOWING IMMUNIZATIONS, PLEASE SPECIFY EXACT DAY, MONTH AND YEAR: YES DAY/MO/YR DAY/MO/YR DAY/MO/YR DAY/MO/YR DAY/MO/YR Measles Mumps Rubella Diptheria Pertussis Tetanus Poliomyelitis BCG Hepatitis B Other TB Test Which type (circle one) Mantoux or Tine Date: Result (+/-) If positive, was chest x-ray done? Yes No Date: Result (+/-) I, the undersigned, certify that a thorough physical examination of the candidate has been given and all important recent medical information has been included on Form 3A and 3B, that nothing relevant has been omitted, and that the candidate is able to travel. I understand that the omission of any information could be harmful to the candidate’s health care and could result in early termination from the AFS program. Physician Name and Degree Address Signature Date

Your signature below attests that you understand and accept the AFS Medical Policies as stated on the Participation Agreement, that the information on Form 3A and 3B is correct and complete and that inaccurate or incomplete information could be harmful to the candidate’s health care and could result in early termination from the AFS program. Candidate Signature: Parent/Legal Guardian Signature: Date: Date:

4 Introduction to Your Host Family

FOR OFFICE USE

AFS ID#

Elijah Daniel Batislaong Geanga

Puerto Princesa

Palawan

Philippines

Candidate Name (First/Middle/Last)

Home City

Home State/Province

Home Country

Just as you are curious about your host family, they will be curious about you. Here is a chance to provide them with a feeling for who you are.
PHOTO PAGE

To help you introduce yourself to a host family, assemble a small collection of photographs showing you, your family and friends. Be creative! Place the photos, with a short phrase to describe the photo, on a single sheet of paper (either A4 or 8 1/2 x 11 inch). Print your name and your country of origin on the Photo Page and on the back of each photo. If possible, make a color copy of this page; this will make it easier for AFS to send overseas and you can keep the original.
INTERESTS AND ACTIVITES

Please identify for your host family your major interests and activities.
My major interests are meeting people from different countries, exploring places, cooking, learning & discovering new things, technologies,
adventures, going to different beach resorts and holding different kinds of animals. Some of my activities are working-out, listening to music,

eating, surfing the internet, and walking around. Food, fun, adventures and friends are the best things for me.

LETTER TO HOST FAMILY

This is your chance to tell your prospective host family about yourself in a letter. Incorporate your answers to the questions below in order to communicate who you are and your motivation for going abroad with AFS. Please do not use the name of country in which you may be interested. Please write your letter in English, even if you submit a second letter in a second language. Your letter should be approximately two pages long. Keep in mind that this will be the first impression your host family has of you. Therefore, type or print legibly in black ink. Please include your letter with this form. Please answer the following questions in the body of your letter.
1 2

How would your family and friends describe your personality? How would you describe your relationship with your family and friends? For example, how are you different from your brother/sisters and/or friends? What is your role in the family? In what types of situations do you seek advice from your parents? Describe in more detail for your host family your major interests and activities and how often you pursue them. What are your different roles in your community (For example: school, sports, community activities)? What is important to you? What was your motivation to apply for the AFS program? What are your personal goals for the program? What part of your daily life do you find frustrating or difficult? Whether or not you have been successful, please describe an obstacle in your life and how you attempted to overcome this challenge. What are your future education or career plans?

3 4 5 6 7 8

Updated Aug 2008

5 Parents Statement

FOR OFFICE USE

AFS ID#

Elijah Daniel Batislaong Geanga Candidate Name (First/Middle/Last)

Philippines Home Country

Please provide a brief statement about your son/daughter covering his/her: 1 2 3 4 5 6 Relationship with you and your family. Relationship with others. Reactions to disagreement and discipline. What is the amount of independence given to your child? How does your child handle challenging or difficult situations? Reactions to being away from home in the past. Please also discuss any factors (e.g., dietary, physical, or health limitations) which you believe should be considered in placing your child in a new environment.

Please use a computer (and paper clip your print-out to this form), type or print legibly in black ink.

Parent/Legal Guardian’s Signature

Date
Updated Aug 2008

Self Permission Form

PL ID#

Elijah Daniel Batislaong Geanga
Name of participant AFS Program of participation PERMISSION TO USE PHOTOGRAPHS AND VIDEO FOOTAGE I understand that photographs and film and video footage (the “images”) of current and former participants are occasionally used by AFS in promotional materials. By signing this Agreement, I grant to AFS the right to use, publish and/or reproduce for any lawful and legitimate purpose excerpts from interviews and letters, images and audio recordings and any other still or moving images of me taken during my involvement with AFS and to use my name in this connection. I understand that if I do not wish my images to be so used, I must mark the following box and initial the space beside it. By leaving this box blank, I understand that I will be deemed to have consented to such use. Initial here if you DO NOT give permission for AFS to use such letters, images and audio recordings of yourself. AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT Should any medical emergency arise, if time permits, AFS will communicate with the person(s) I have designated below as the emergency contact(s) through the National Office and request permission for surgery or other necessary treatment; however, if in the sole judgment of AFS, time and circumstances do not permit communication with them, I authorize AFS to consent to medical treatment, the administration of x-ray examination, anesthetics, blood transfusion, medical or surgical diagnosis or treatment and hospital care and to make medical evacuation arrangements and transport, if required, which is deemed advisable by, and is to be rendered under the general or special supervision of any physician and surgeon. I am aware that some local government may require certain vaccinations in order for myself to participate in community responsibilities. I understand that I am responsible for any costs related to these requirements. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION I hereby authorize AFS, and/or its duly authorized medical consultant, to obtain all medical records relating to examinations or treatments for me while I am on the program and any other information concerning such examinations or treatments. AGREED AND ACCEPTED: Date

Signature of participant

27
Participant’s Birthdate: day

May
month (spell word) year

1996

Elizabeth B. Geanga
Name of emergency contact

Mother
Relationship Home phone

+63 (947) 775 8594
Work phone Address

Sitio Gotok, Brgy. Sandoval, Bataraza, Palawan

6 Parental Authorization Form

FOR OFFICE USE

AFS ID#

Candidate Name (First/Middle/Last)

Elijah Daniel Batislaong Geanga

Home Country

Philippines

20 October 2013
Date

PERMISSION TO USE PHOTOGRAPHS AND VIDEO FOOTAGE

We understand that photographs and film and video footage (the images) of current and former candidates are occasionally used by AFS in promotional materials. By signing this Agreement, we grant to AFS the right to use, publish and/or reproduce for any lawful and legitimate purpose excerpts from interviews and letters, images and audio recordings and any other still or moving images of the candidate taken during his/her involvement with AFS and to use his/her name in this connection. We understand that if we do not wish the candidate’s images to be so used, we must mark the following box and initial the space beside it. By leaving this box blank, we understand that we will be deemed to have consented to such use. If you initial here, you confirm that you DO NOT give permission for AFS to use such letters, images and audio recordings of your child. In this case, your child may not be allowed to be part of AFS group photos, etc.
AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT

Should any medical emergency arise, if time permits, AFS will communicate with us through the National Office and request permission for surgery or other necessary treatment; however, if in the sole judgment of AFS, time and circumstances do not permit communication with us, we authorize AFS to consent to medical treatment, the administration of x-ray examination, anesthetics, blood transfusion, medical or surgical diagnosis or treatment and hospital care and to make medical evacuation arrangements and transport, if required, which is deemed advisable by, and is to be rendered under the general or special supervision of any physician and surgeon. We are aware that some local government or school authorities may require certain vaccinations in order for our child to participate in school or community responsibilities. We understand that we are responsible for any costs related to these requirements.

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

We hereby authorize AFS, and/or its duly authorized medical consultant, to obtain all medical records relating to examinations or treatments for our son/daughter while on the program and any other information concerning such examinations or treatments.
PERMISSION FOR SCHOOL SPONSORED ACTIVITIES (FOR SCHOOL-BASED PROGRAMS ONLY)

We authorize the AFS host parents for my son/daughter during his/her participation in the AFS program to execute any authorization required by our son/daughter’s school for our son/daughter to participate in any school sponsored activities, events or programs.

SCHOOL COMMITMENT (FOR SCHOOL-BASED PROGRAMS ONLY)

The student fully understands that this AFS program is school-based and family-oriented. The student intends to participate fully in school activities and to complete all assignments and schoolwork while on exchange. We understand that school is compulsory. If the student should neglect the above, AFS and/or the host school has the right to deny his/her participation in classes and s/he may be sent home.
AGREED AND ACCEPTED BY

(Signature of Natural Parent)

(Signature of Natural Parent)

Signature of Candidate

Candidate’s Birthdate: day

27

month (spell word)

May

year

1996

Updated Aug 2008

Elijah Daniel Batislaong Geanga
Canditate Name (First/Middle/Last)

Philippines
Home Country

Big Lagoon in El Nido, Palawan, Philippines

Sheridan Beach Resort and Spa in Puerto Princesa City, Palawan, Philippines

Elijah Daniel Batislaong Geanga
Canditate Name (First/Middle/Last)

Philippines
Home Country

Together with a friend in Bulalacao Falls, Palawan, Philippines

Skywalk Extreme at Crown Regency Hotel & Towers in Cebu City, Philippines

Elijah Daniel Batislaong Geanga
Canditate Name (First/Middle/Last)

Philippines
Home Country

Beautiful Sunset in Boracay, Philippines

Chocolate Hills in Bohol, Philippines

Elijah Daniel Batislaong Geanga
Canditate Name (First/Middle/Last)

Philippines
Home Country

I love to hold wild kind of animals like snakes, tiger, bearcat, crocodile & etc.

I like watching movies in the cinemas with friends.

Wearing the Zorro Costume during an AFS Activity

Elijah Daniel Batislaong Geanga
Canditate Name (First/Middle/Last)

Philippines
Home Country

My classmates when I was in high school

During my graduation day

My mother and father during our vacation

Candidate Signature

Date

Greetings! I am Elijah Daniel B. Geanga, 17 years old. My mother is Elizabeth and my father is Ephraim. My mother is an elementary teacher in a public school while my father is a retired electrician and now a farmer of our own rice farm. I am currently in college pursuing Bachelor in Secondary Education Major in English. I should have a sister but she died in an early age of 1 year old and 7 months because of cardiovascular problems. My family would describe me that I am outgoing, very sociable, talkative, helpful, and always ready to do the household chores. They told me that I really know how to interact with others, with the students, teachers, foreigners and even those professionals. According to some of my friends, I am open-minded, a very generous man, even sometimes I forget myself. They told me that I am always ready to help everyone and I could never say “no” or in an easy way of saying that I don’t know how to refuse others, even though I still have some tasks to do. If you ask me about computers or something that favored me that is connected to computers, I always try to help. They told me that I am pleasing everybody of those requests. Some of my teachers told me that I am always conscious about my looks, if I am well-groomed, handsome and look good always. They told me that I have an attractive personality, kind-hearted, humble and nice. When I asked one of my best friends about my attitude he answered: “You are a kind of man who knows how to listen and will not make any unnecessary conversations with others. You are very flexible and you really know how to deal with different situations.” My relationship with my family is very good, when it comes to family matters I am quite serious and I always find time to have a conversation with them about my decisions, problems and stories. As what I had stated before that I don’t have any brothers or sisters because my sister died in an early age of one year old and seven months because of cardiovascular problems. There are also some types of situations that I seek an advice from my parents like if I am troubled in school specifically about my classmates. I also seek their advice about my studies, travels and what should will I do if I encounter some problems. My relationship with my friends is excellent. It is such a great feeling that you have a lot of friends coming from different parts of the world. I usually find time to be with my friends and we usually do a lot of activities together like watching movies in the cinema, eating together, sharing stories and having fun together. I can say that I am quite different with my friends because I usually concentrate with activities like travelling, meeting more people and trying to be more serious in my life. I think I am more ambitious and I have a lot of goals in my life. I seek for success unlike most of my friends would tell me that they are contented for what they have. To sum it up, I am really seeking forward to make a difference. My major interest are meeting a lot of people, exploring places, cooking, learning & discovering new things, technologies, and adventures, going to different beach resorts and holding different kind of animals. I usually find time for my work-out. I really love music such us country songs and reggae’s. I also like eating different kind of foods and walking around especially in the park. Sometimes, I find a convenient time to go to a bar and drink something but not too much. Usually, I am very flexible and easy going, I am very thankful for whatever activities.

I have a different role in my community. In school, I usually run errands for the student as well as with the teachers if they need something. I had been a class mayor for 3 consecutive years and I had been a president of a library club. Right now, I decided not to have a part in any school government organizations because I wanted to concentrate in my studies. In community activities, I always try to get involved in any activity like tree planting, community service, coastal clean-ups, feeding program, run for fun and many more. I am always active and willing to help and to give contributions in my community. When I was still a child I dreamed of going out of my country. As I grow older I tried to seek an open gate that will help me to let a new experience to other country. It was my first year in college when I discovered AFS. It was my first time to know meet a lot of people coming from different countries and as they tell their stories about their country and about their activities and culture the more that I am motivated to apply for an AFS Program. My personal goals for the program are to share something about my culture, tradition, society, values, and education. I don’t have any part of my life that I found frustrating and difficult. As what I have told you earlier I am easy going and flexible. I think if you know how to face problems and how to solve and deal with it you will not find any frustrations in your life. Whether I had been successful or not I can still say that the greatest results in life are usually attained by simple means and the exercise of ordinary qualities. These may for the most part be summed in these two: commonsense and perseverance. My greatest dream in life is to always live my life with a heart full of love, kindness, peace and humility. For now, my main target is to finish my studies as an educator. In the future, I want to have a better job so that I can support my family and so that I can pay back my parents. I want my life to be more productive where I can obtain what I wanted and have everything that I need. I also want to establish an organization that helps people in need. Doing good deeds lightens my mind and makes me happy. Sincerely yours,

Elijah Daniel Geanga

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