Global Teen Leadership Application | YMCA of Northern Colorado

Student Information

Student’s Legal Name

Date of Birth

Age

Gender

Current Grade

School

Address

City

State

Zip

Phone

Place of Birth (City, State, Country)

Country of Citizenship

Passport Number (All students must have the ability to secure and provide a copy of a valid US passport by March 1, 2020 in order to participate.)

Date Passport Issued

Expiration Date (The passport cannot expire within 6 months of travel.)

Family Information

Name - Parent/Guardian 1

Relation

Address

City

State

Zip

Phone

Name - Parent/Guardian 2

Relation

Address

City

State

Zip

Phone

Additional Emergency Contacts

Name - Emergency Contact 1

Relation

Address

City

State

Zip

Phone

Name - Emergency Contact 2

Relation

Address

City

State

Zip

Phone

Health Information

Physician

Address

City

Phone

Insurance Company

Policy #

Allergies (List Types)

Reactions If Exposed

Treatment

Dietary Restrictions

Reasons

Physical Limitations

Reasons

Any additional health information we should be aware of

Routine Medications (Please list any medications you will need to bring on the trip.)

Treatment for

Times

Have you required any hospital treatment, including surgeries, in the past year?

No
Yes

If yes, please explain.

Do you currently have ongoing health issues?

No
Yes

If yes, please explain.

Participation Agreement

By checking the boxes below, you and your parent/guardian agree to the following:

Are there any health-released issues which might affect your fitness to travel?

No
Yes

If yes, please explain.

I and my parent/guardian…

Understand that full participation in the workshops are required prior to participating in the Peru trip.

I and my parent/guardian…

Understand that a valid passport that expires no sooner than January 1, 2020 must be provided to the YMCA by March 1, 2020.

I and my parent/guardian…

Understand that payment of $3800 must be paid in full to the YMCA by June 1, 2020. Payment schedule to the Y may be arranged.

I and my parent/guardian…

Understand that all payments are final and no refunds will be provided if I/my student chooses to withdraw from the program (space is limited and plane tickets are pre-booked by March 1, 2020, as well as all accommodations in Peru). Extenuating circumstances for withdrawal must be approved by the CEO at the YMCA.

I and my parent/guardian…

Understand that I/my student’s spending money is not included in the quoted fee. This is an additional expense and must be provided by the student/family. The suggested spending amount is $300 per student for any personal purchases such as gifts, snacks or souvenirs.

I and my parent/guardian…

Understand that if I/my student requires medication during their travel, I must supply a minimum of 20 days prior to departure of the trip.

I and my parent/guardian…

Understand that I must supply the YMCA with copies of my/my student’s immunization records.

I and my parent/guardian…

Understand that this exchange program has an emphasis on responsible citizenship, service and leadership development and I/my student agree(s) to follow all safety expectations and guidelines set forth by YMCA and BVSD staff members.

Student Background

Please provide details of any previous or current volunteer or work experience.

Organization

Dates with Organization

Reference or Contact Name

Contact Info (phone/email)

Responsibilities/Duties Performed

Organization

Dates with Organization

Reference or Contact Name

Contact Info (phone/email)

Responsibilities/Duties Performed

Please list any skills you have which relate to overseas service learning including, but not limited to working with children/youth, working with people with disabilities, working with elderly people, arts and crafts, sports and leading games, etc.

Do you speak other languages?

Yes
No

If yes, please list languages and fluency levels (basic, verbal, written, fluent):

Have you had any international experiences in the past? If so, please describe:

Please describe yourself, including your strengths, opportunities for growth, and leadership style:

What are your future plans?

Have you been involved in any organizations, movements, service programs and other projects? If so, please give details:

What does service learning mean to you?

Please describe briefly a national and/or international issue that has affected you:

What are your main reasons for wanting to participate in this program and travel to Peru?

What do you hope to gain from and achieve during this program and exchange trip?

What challenges and difficulties do you think you will encounter living in another culture with a different set of values?

When faced with a personal conflict, how do you tend to respond?

Please tell us anything else you think we should know about you, your goals, and/or your motivations for applying for this program:

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GLOBAL TEEN LEADERSHIP

APPLICATION

Student Information

Family Information

Additional Emergency Contacts

Health Information

Participation Agreement

Student Background

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