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CENTRAL AMERICA YOUTH

AMBASSADORS PROGRAM - 2017 CYCLE

U.S. YOUTH APPLICATION

Background

Georgetown University’s Center for Intercultural Education and Development (CIED), the Bureau of Educational
and Cultural Affairs of the State Department and the U.S. Embassies in Central America are pleased to
announce the launch of candidate recruitment for the 2017 Central America Youth Ambassadors (CAYA)
program.

The CAYA program provides youth and adult mentors from the United States, specifically from Huntsville,
Alabama; Moscow, Idaho; Marquette, Michigan; Jacksonville, Florida; and Washington, DC, the opportunity for
a three week international exchange in Nicaragua and the Dominican Republic. During this youth diplomacy
experience participants will travel to the Dominican Republic and Nicaragua where they will have interactive
workshops, community service activities, field trips and cultural outings with local youth and community
leaders. These study tours will expand their knowledge of the culture, society and education in Central America
and the Caribbean. The CAYA program will be conducted in English and participants are encouraged to practice
their Spanish, improving their language skills. The Youth Ambassadors program not only provides participants
with new knowledge and unmatched experiences, it also develops new leadership skills and strengthens
commitment to civic engagement, social entrepreneurship and environmental initiatives.

Candidate Profile

 15 to 18 years old  No close relative who has previously
 Citizenship: United States participated in the CAYA program
 Still has one more year of high school after  Demonstrated leadership skills and
the completion of the Program entrepreneurial and environmental interest
 Public high school student and/or  Personal characteristics such as maturity,
participation in a community-based project integrity, social skills, open-mindedness
 Economically disadvantaged background and motivation
 Intermediate level of Spanish

Participants for the 2017 program will be chosen through a selection process coordinated by GU/CIED, the
Education and Cultural Affairs Bureau of the Department of State and local partner institutions.

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2017 YOUTH APPLICATION FORM

INSTRUCTIONS

Please carefully read this application form before filling it out. You must answer all the questions and attach all
the required documentation for your application to be considered. If some questions do not apply please write
N/A (not applicable). Complete and send application to:

Anna Marie Siegel
Florida State College at Jacksonville
asiegel@fscj.edu
Phone: (904)632-3248

DOCUMENTS REQUIRED

Please send the following documentation with your application*:

1. Copy of birth certificate
2. Two passport pictures
3. Copy of valid passport if possible (it is not mandatory to have a passport to apply to the program)
4. Copy of parents/legal guardians’ valid ID
5. Application form
6. Annexes (See annexes attached at the end of this application form):

 Annex # 1: Letter of Recommendation # 1
 Annex # 2: Letter of Recommendation # 2
 Annex # 3: Parental Authorization
 Annex # 4: Liability Waiver and Authorization for Medical Treatment
 Annex # 5: Medical Certificate Addendum
 Annex # 6: Code of Commitment
 Annex # 7: Questionnaire for host family stay

* Note: Please do not send the original documents. All documentation sent to Georgetown University will not
be returned.

IMPORTANT DATES (Check with the CAYA local coordinator for specific dates)

 January 20th to February 28th, 2017 Candidate recruitment period
 February 28th to March 10th, 2017 Candidates interview and pre-selection process
 March 30th, 2017 Final selection by Georgetown U. and the Department of State
 June of 2017 (Specific date TBD) Pre-departure orientation
 July 9- August 2, 2017 Three weeks of CAYA Program in the Dominican
Republic and Nicaragua

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Please attach two (2)
pictures

__________________________ ___________________ ___________________________
First Name Middle Name Last Name

__________________________ ___________________ __________________________
Date of Birth Age State
(month/day/year)

Tell us a little bit about yourself and your family:

Tell us a little bit about your hobbies and interests:

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I. PERSONAL INFORMATION

Name:
Last Name First Name

Street:
Street Name and Number City and State

Contact Information:
Phone Number (complete) E-mail

II. BIOGRAPHIC DATA

1. Place of Birth: _________________________ ________________
City Country

2. Date of Birth: _________________________
(month/day/year)

3. Gender: Female Male

4. Marital Status: Married Single

5. Ethnic Background: Caucasian American Indian African American

Asian or Pacific Islander Hispanic Eskimo or Aleut

Other, please specify__________________________________________

6. Do you have any physical disability? No Yes Explain:_____________________________

7. Do you have any medical condition? No Yes Explain:_____________________________

III. EDUCATIONAL BACKGROUND

1. Schools Attended:

Starting Ending
Name of Institution Major Field Degree Received
year year
Primary School

High School

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2. Indicate any awards or academic honors received:

_________________________________________________________________________________

3. Have you ever attended a private school? Yes No

4. Have you ever received a scholarship or financial aid? Yes No

5. If your answer to question #4 is yes, please give the following information:

 How much money did you receive? (Amount): $ ________________________________________

 Who gave it to you? (Institution): ____________________________________________________

 For how long did you receive this financial aid? (Period): _________________________________

6. Are you currently enrolled in school? Yes No

7. If your answer to question # 6 is yes, answer the following questions:

a. Types of classes: Day Night

b. Current GPA: ______________________

c. Name of the institution you are attending: ______________________________________________

d. Indicate your major area(s) of study: ___________________________________________________

e. When do you plan on graduating: __________
Month and Year

8. Do you speak any languages other than English? Yes No

If yes, please complete the section below. Use the following letters to rate your ability:
E = Excellent G = Good F = Fair

Speaking Reading Writing
Language Learned Where Years of Study
Level Level Level

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IV. WORK EXPERIENCE

1. Have you ever worked? (Including both formal and informal jobs) Yes No

2. If your answer to question #1 is yes, please give the following information based on your most recent jobs:

Job 1

1. Name of company where you work/worked:

2. What is/was your position?

3. Provide a brief description of your responsibilities:

_________________________________________________________________________________

4. What are/were your beginning and ending dates of employment?

__________________ __________________
Beginning date Ending Date

5. What is/was your monthly salary? ___________________

6. How many hours you work/worked per week? _______________

Job 2

1. Name of company where you work/worked:

2. What is/was your position?

3. Provide a brief description of your responsibilities:

_________________________________________________________________________________

4. What are/were your beginning and ending dates of employment?

__________________ __________________
Beginning date Ending Date

5. What is/was your monthly salary? ___________________

6. How many hours you work/worked per week? _______________

V. FAMILY INFORMATION

1. With whom do you live? Mark all the appropriate responses

Father Mother Guardian Siblings Other: ____________

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2. Name of Mother/Legal Guardian: ___________________________ _________________________
Last Name First Name

Name of Father/Legal Guardian: ___________________________ _________________________
Last Name First Name

3. Do you have any family member that has participated in the CAYA program? Yes No

4. Have you ever traveled out of the country? Yes No

5. If your answer to question #4 is yes, please mark the reason why you travelled?

Tourism

Other: ________________________________________________________

6. Have you ever traveled to Central America? Yes No

7. If your answer to question #6 is yes, please mark the reason why you travelled?

Tourism

Other: ________________________________________________________

8. Do you have a passport? Yes No

9. If your answer to question #8 is yes, please give the following information:

Passport Number: ______________________ Place of Issue: _____________________

Issuing Country: ________________________ Date of expiration: _________________
(month/day/year)

10. Emergency Contact Information. It is very important that we have an emergency contact other than your
permanent address.

Name:
Last Name First Name

Relationship to applicant: _________________________________________________________________

Street: ______
Street Name and Number City and State

Contact Information: ______
Phone Number E-mail

11. Please indicate the person or organization that gave you this application form:

_______________________________________________________________________________
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VI. QUESTIONS FOR THE APPLICANT

Please provide answers to the following questions. Answers should be as specific as possible.

1. Suitability of the applicant: Why do you feel you are an ideal candidate for this exchange experience?
Please explain.

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2. Community involvement: Write about an environmental problem currently affecting your community. If it
were within your abilities, how would you solve this problem?

____________________________________________________________________________________

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3. Leadership: Please list your extracurricular activities and/or your involvement in community groups in the
spaces provided below. Be specific about your responsibilities and leadership roles.

Period
Activities Position Held Location
(Dates)

Have you been a
member of an
extracurricular club
or association at
school?
If yes, explain:

Have you
participated in
entrepreneurial
and/or
environmental
initiatives? If yes,
explain:

Have you
participated in any
community-based
activities? If yes,
explain:

I certify that the information contained in this application, including all attachments and supporting
credentials, is complete and correct.

_____________________________________ ___________________________________
Applicant’s signature Date

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ANNEX #1 Central America Youth Ambassador Program
Letter of Recommendation for Youth # 1

INSTRUCTIONS:

This form should be filled out by someone who has worked directly with the applicant (teacher, supervisor,
community leader, etc.). Recommendations from friends or relatives will not be accepted.

Applicant’s Full Name

Name of Recommender ___ ____________________________
Name Title
Institution

Your opinion about the applicant will be a great help in the selection process. It is very important that your
comments and responses are sincere and detailed. After completing this form, please return it to the applicant
in a sealed and signed envelope. Thank you for your cooperation.

1. How long have you known the applicant and in what capacity?

2. In the following table, please indicate the intellectual capacity and personality of the applicant compared to
his/her peers.

Below
Qualities Unsatisfactory Average Very Good Excellent
Average
Ability to express
his/herself
Ability to take on
responsibilities
Motivation and
entrepreneurial spirit
Maturity and ability to
work with others
Youth leadership
qualities/potential

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3. Describe situations in which the applicant has shown leadership skills and entrepreneurial or environmental
spirit.
_______

_______

4. How does the applicant interact with his/her peers and teachers? Are there some aspects of the applicant’s
behavior that could be improved?

_______

_______

5. Give an example of how the applicant has successfully adapted to a new or different situation.

_______

_______

6. What are some of the applicant's outstanding personal characteristics? Please mention below any additional
information that you consider important for evaluating the applicant.

_______

_______

Signature of Recommender Date

Name Position

Name, Address, and Telephone Number of the Office or Institution:

_______

_______

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ANNEX #2 Central America Youth Ambassador Program
Letter of Recommendation for Youth # 2

INSTRUCTIONS:

This form should be filled out by someone who has worked directly with the applicant (teacher, supervisor,
community leader, etc.). Recommendations from friends or relatives will not be accepted.

Applicant’s Full Name

Name of Recommender ___ ____________________________
Name Title
Institution

Your opinion about the applicant will be a great help in the selection process. It is very important that your
comments and responses are sincere and detailed. After completing this form, please return it to the applicant
in a sealed and signed envelope. Thank you for your cooperation.

1. How long have you known the applicant and in what capacity?

2. In the following table, please indicate the intellectual capacity and personality of the applicant compared to
his/her peers.

Below
Qualities Unsatisfactory Average Very Good Excellent
Average
Ability to express
his/herself
Ability to take on
responsibilities
Motivation and
entrepreneurial spirit
Maturity and ability to
work with others
Youth leadership
qualities/potential

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Any false information submitted will cause the immediate disqualification of the candidate
3. Describe situations in which the applicant has shown leadership skills and entrepreneurial or environmental
spirit.
_______

_______

4. How does the applicant interact with his/her peers and teachers? Are there some aspects of the applicant’s
behavior that could be improved?

_______

_______

5. Give an example of how the applicant has successfully adapted to a new or different situation.

_______

_______

6. What are some of the applicant's outstanding personal characteristics? Please mention below any additional
information that you consider important for evaluating the applicant.

_______

_______

Signature of Recommender Date

Name Position

Name, Address, and Telephone Number of the Office or Institution:

_______

_______

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Any false information submitted will cause the immediate disqualification of the candidate
ANNEX #3 Central America Youth Ambassador Program
Parental Authorization

I/We hereby grant permission for my/our son/daughter ________________________________, to participate
in the 2017 Central Youth Ambassadors Program that will be held in Nicaragua and the Dominican Republic.

___________________________ ______________________________ _____________
Name of Mother/Legal Guardian Mother/Legal Guardian’s Signature Date

___________________________ ______________________________ _____________
Name of Father/Legal Guardian Father/Legal Guardian’s Signature Date

Note:
•In the case where one of the parents is deceased, please provide a copy of the death certificate.
•If parents are separated or divorced, please provide information on the parent not living in the student's
household.

Contact Information:

Street:
Street Name and Number City and State

Contact Information:
Phone Number (complete) E-mail

This material is free. It’s sale is illegal.
Any false information submitted will cause the immediate disqualification of the candidate
ANNEX #4 Central America Youth Ambassador Program
Liability Waiver and Authorization for Medical Treatment

This form applies to all candidates who intend to participate in the Central America Youth Ambassadors
Program (CAYA). This form must be signed by the parents or guardians if the student is under 21 years of age.
This document establishes the following:

 Authorization to participate in the CAYA Program, which includes travel to Nicaragua and the Dominican Republic and
all program activities during the three week exchange.
 Authorization permitting the Program Director, or his or her designee, to obtain medical treatment in the event that
such a need should arise while the student is abroad. In the event of sickness or personal injury, I hereby authorize the
Program Director, or his or her designee, to secure whatever treatment is deemed necessary, including the admission
to a hospital, the administration of anesthetics, the transfusion of blood, and surgery. All necessary precautions will
be taken to avoid accidents and mental and/or physical health problems, however, program officials must be in a
position to act should such need arise.
 Authorization permitting any medical or health care provider to release any and all medical histories and
documentation on the student to Georgetown University and/or the partner CAYA educational institution in
Nicaragua and the Dominican Republic.
 Acknowledgement that while the participant is in Nicaragua and the Dominican Republic, Georgetown CIED has
enrolled him/her in an adequate medical insurance program, specifically the Accident and Sickness Program for
Exchanges (ASPE) sponsored by the U.S. Department of State.
 Acknowledgement that student is travelling to a country on the Centers for Disease Control (CDC) list for the Zika
disease (please ensure that you review the CDC website for Zika facts and recommended preventative measures).
 This Authorization releases the U.S. government, Georgetown University and all Program representatives, employees,
volunteers, and officers from any and all claims or causes of action for loss of property, mental and/or physical illness,
personal injury or death sustained by the participant arising out of any travel or activity conducted by, in support of,
or under the auspices of this Georgetown University Program.

Your signature constitutes your acceptance of these terms and conditions:

Participant Name: ________________________________ State: ______________________

Participant Signature: _____________________________ Date: ________________________
……………………………………………………………………………………………………………………………………………………………………………

For participants younger than 21 years old:

Your signature constitutes your review and acceptance of these terms and conditions:

I hereby give permission for __________________________, (name of participant) to
participate in the CAYA Program to be held in Nicaragua and the Dominican Republic.

I understand that Georgetown University has enrolled _________________, (name of
participant) in a medical insurance program sponsored by the U.S. Department of State, the Accident and
Sickness Program for Exchanges (ASPE), which will provide coverage of reasonable and eligible health care
costs beginning on the day of departure continuing throughout the term of the CAYA exchange in Central
America.

_____________________________ ________________________________ _____________
Name of Father or Legal Guardian Signature of Father of Legal Guardian Date

_____________________________ ________________________________ _____________
Name of Mother or Legal Guardian Signature of Mother of Legal Guardian Date
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ANNEX #5 Central America Youth Ambassador Program
Medical Certificate Addendum

1. Participant’s Name: _______________________________________________________________

2. Date of Birth:__________________________ Place of birth:_________________________

3. Childhood diseases: _______________________________________________________________

4. Surgeries: _______________________________________________________________________

5. Allergies or dietary restrictions:______________________________________________________

6. Allergies to medicine (like penicillin): _________________________________________________

7. Infectious diseases: _______________________________________________________________

8. If participant has epilepsy, please indicate:

- Type of seizures: Gran Mal Petit Mal

- Frequency of seizures? _________________

- If taking any epilepsy medications please detailed the name and dosage: ____________

________________________________________________________________________

9. Is the participant diabetic? No Yes Medications? __________________________

10. Is the participant asthmatic? No Yes Medications? __________________________

11. Vaccines: Please attach your vaccination official records all documentation for past vaccinations

Vaccination date
Type of Vaccine
(month/day/year)
Diphtheria

Tetanus

Rubella

Measles

Chicken Pox

Poliomyelitis

Mumps

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12. Does the participant have any history or present evidence of nervous, emotional, or mental problems?

Yes No

If yes, please explain:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

13. Will the student be taking any prescribed medication during the exchange trip?

Yes No

If yes, what medication?

Generic name, dosage, and reasons of medication:

______________________________________________________________________________

______________________________________________________________________________

Note: Some medications are restricted in certain countries; please have the student check at YFU
USA (http://yfuusa.org/). Students should carry a prescription for their medication when they travel;
the generic name of the drug should be noted on the prescription.

14. Is the participant willing to eat?*

Fish/Shellfish Yes No Poultry Yes No

Pork Yes No Beef Yes No

Dairy Yes No Everything Yes No

* If vegetarian, keep in mind that the program will try to offer you a special menu but in some
circumstances the options may be limited.

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ANNEX #6 Central America Youth Ambassador Program
Code of Commitment

By accepting to be a participant in the Youth Ambassadors program I acknowledge that I understand and
commit to the program goals and expectations and that I acknowledge that I am responsible for my actions and
behavior during the three-week program in Nicaragua and the Dominican Republic. I understand that
Georgetown University has rules and behavior to follow that I will obey, together with the laws of Nicaragua
and the Dominican Republic.

The following principles reflect the conduct expected of each participant in the Youth Ambassadors program:

1. Attend all activities of the Youth Ambassadors program, comply with all the tasks assigned in the
program, and participate actively.

2. Accept local customs and share my own culture with other people in the communities visited,
especially during the host family stay and with other young people from the program.

3. Maintain proper personal hygiene.

4. Respect the rights and differences of all who comprise the group, taking into account that both women
and men and all the people from other races and religions must be treated equally with fairness and
respect.

5. Be responsible for safeguarding your own money and valuables to reduce the risk of loss or theft. The
Program will not be responsible for loss of money or valuables.

6. Moderately use electronic equipment, such as computers, Internet, tablets or phones. When staying
with host families, always request permission to use the equipment. Computer and telephone use
should be limited so that you can dedicate time with your host family.

7. Do not violate U.S. federal or state laws, which prohibit:

a. Purchase and/or consumption of alcoholic beverages if you are under 21 years of age
b. Purchase, sale and/or use of drugs
c. Rape or sexual assault
d. Sexual harassment, threats or intimidation (verbal, written, physical) of any kind
e. Shoplifting
f. Carrying weapons (guns, knives, etc.), insult or assault

Disciplinary Policy

Any failure to comply with the laws of the United States, the participating overseas countries and/or rules of
the program will result in an official warning and may be the cause for which the participant is dismissed from
the program. People who commit a violation of local, state and federal regulations shall be subject to a legal
process under the judicial system in Nicaragua and the Dominican Republic. A participant may be prosecuted
and sentenced to a term of imprisonment if found guilty.

_________________________________ ________________________________ ___________
Participant’s Name Participant’s signature Date

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ANNEX #7 Central America Youth Ambassador Program
Questionnaire for host family stay

Name ________________________________________ Age ______ State ___________________

1. Do you speak Spanish? No____ Yes____ How well?________________________________
2. Do you have siblings? No ____ Yes____ How many?________________________________
3. Do you like pets? No ____ Yes____ Which ones?_______________________________
4. Do you have allergies? No ____ Yes____ To what?__________________________________

5. What type of food do you like? ________________________________________________________
____________________________________________________________________________________

6. Do you have any dietary restrictions? ________________________________________________
____________________________________________________________________________________

7. What is your t-shirt size? XS S M L XL XXL

8. Please list what time you usually do the following activities:

● Wake up _______ ● Breakfast ________
● Eat dinner _______ ● Go to bed ________

9. What would you like to talk/learn/experience with your host family?
____________________________________________________________________________________
____________________________________________________________________________________

10. What do you think will be your biggest challenge during your stay with the host family?
____________________________________________________________________________________
____________________________________________________________________________________

11. What kind of responsibilities/tasks would you like to have during your stay with the host family?
____________________________________________________________________________________
____________________________________________________________________________________

12. How would you like to resolve conflicts that may arise while you stay with your host family?
____________________________________________________________________________________
____________________________________________________________________________________

This material is free. It’s sale is illegal.
Any false information submitted will cause the immediate disqualification of the candidate