Welcome to the ERGO Youth Exchange 2015!

Transcription

1 Welcome to the ERGO Youth Exchange 2015! Please print the following pages and fill in all forms! As soon as you have completed your application, please upload the document (preferred as a PDF) and send it to Ariane.Schmerse@afs.de or via Fax +49 (0) You can send it also via mail to Ariane Schmerse Friedensallee Hamburg GERMANY In case of any question, please feel free to contact Ariane Schmerse the designated Program Manager of this Exchange Program. We will be happy to help you. We are looking forward to receive your application for the ERGO Youth Exchange 2015! Good luck and best regards, Your AFS Team

2 ERGO Youth Exchange Program Coordinated by AFS Intercultural Programs Candidate Application Attach Photo Here Name: Country Choice: First Choice: Second Choice Third Choice

3 Personal Information Candidate's Name ERGO Youth Exchange 1. Name and Address First Name: Street: Telephone: Fax: Address: Last Name: Postal Code and City: Mobile Phone: Mobile Phone Parents: Birthday(day/month/year): 2. Family Data I live with: Mother and Father Mother and Partner Father and Partner Mother Father Other: Please circle your legal guardian(s)! Father/Stepfather/Guardian First Name: Year of Birth: Working for ERGO: Yes No Last Name: Country of Birth: Department: Mother/Stepmother/Guardian First Name: Year of Birth: Working for ERGO: Since(Month/Year): Personal Employee Number: Employed with a fixed-term work contract: Employed with a permanent work contract: Last Name: Country of Birth: Yes No Department: 3. Emergency Contact First Name: Street: Home phone: Last Name: Postal Code and City: Mobile phone: 4. Brothers and Sisters Name: Name: Name: Birthday: Birthday: Birthday: Living at home? Living at home? Living at home? Yes No AFS Interkulturelle Begegnungen e.v., Friedensallee 48, Hamburg,

4 Placement Information Candidate's Name ERGO Youth Exchange 1. Medical Requirements and Health Restrictions Do you have physical restrictions, impairments or allergies that will limit placement options or participation in everyday family and/or school activities? Yes No If yes, please explain: I cannot live with: Cats Dogs Other pets: 2. Dietary Requirements Do you have dietary (eating) restrictions, including for medical, religious or self-imposed reasons? Yes No If yes, please explain: If you are a vegetarian, are you willing to eat: Fish Poultry Dairy products 3. Smoking Do you smoke? Yes No Must you be hosted in a non-smoking home? Yes No 4. Religion What is your religious affiliation? Catholic Protestant Jewish Muslim None Other: How often do you attend services? Regularly Occasionally Never 5. Languages Native Language: Studied Languages: Language: Years studied: Speaking ability: Poor Fair Good Excellent Language: Years studied: Speaking ability: Poor Fair Good Excellent AFS Interkulturelle Begegnungen e.v., Friedensallee 48, Hamburg,

5 Self Description Candidate's Name ERGO Youth Exchange 1. Hobbies and Leisure Activities Sports practised: Leisure Activities practised (Music, Art etc.): Other Interests: 2. How do you like to spend your free afternoons and weekends? Preferably (in order of preference 1-5, 1= best) At home with your family At home with friends On excursions with your family On excursions with friends Other: 3. I am best described as: Calm/Reserved Energetic/Outgoing Socially Active Academic Athletic Shy 4. Letter of Motivation and Self Characterization On a separate piece of paper, please write a letter (computer, type size 12) explaining your motivation why you would like to participate in a student exchange and how you imagine to contribute to your host country and your host family. Similarly, write what you hope to gain from the experience. Please describe yourself, your character strengths and weaknesses or what really matters to you (hobbies, favourite subject, personal idol e.g.). The questions below may be used as a guideline: Have you already gained any experience in a foreign country (class trip, vacation, e.g.) or with people from a foreign culture? What did you especially like and how did you manage problems that may have occurred (language problems, misunderstandings due to the culture e.g.)? How would you describe your relationship with your family and friends, what is your role in the family. What would you consider to be the most important experience you ve made in life so far? What you don t like or what really angers you. AFS Interkulturelle Begegnungen e.v., Friedensallee 48, Hamburg,

6 Photo Page Candidate's Name ERGO Youth Exchange Please attach some nice photos of yourself, your family and your home. You may add more pages if you like. AFS Interkulturelle Begegnungen e.v., Friedensallee 48, Hamburg,

7 Placement Information Candidate s Name ERGO Youth Exchange 1. Details about the host student Girl Boy We have no preference. 2. Accommodation How do you live? Rural House Big Urban Apartment Small Will the student have his own room? Yes No 3. Pets Do you have pets? Yes: Do they live inside the house? Yes No No 4. Dietary Requirements Do you follow any diet (vegetarian, vegan,.)? Yes No if yes, please explain: Would you accept a student who is vegetarian? Yes No 5. Smoking Would you accept a student who smokes? Yes No 6. Religion What religious affiliation has your family? Catholic Protestant Jewish Muslim None Other: How often do you attend services? Regularly Occasionally Never 7. Languages Native language: Other languages spoken in family: 8. Other Placement preferences AFS Interkulturelle Begegnungen e.v., Friedensallee 48, Hamburg,

8 Host Family Description Family Name: ERGO Youth Exchange Description of each member of the family: Description of family life: Description of the neighbourhood (home, residence, nearest city ) 3. AFS Interkulturelle Begegnungen e.v., Friedensallee 48, Hamburg,

9 AFS Interkulturelle Begegnungen e.v., Friedensallee 48, Hamburg,

10 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, 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. (Ms.) (Mr.) Candidate Name (First/Middle/Last) Home Country Birthdate 1 Height Weight B/P Pulse Respiration Blood Type 2 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 C HECK YES OR NO. HAS THE CANDI DATE HAD THE DISEASES / CONDITIONS LISTED BELOW: YES NO IF KNOWN: a) Measles Titer: Date: h) Rheumatic Fever b) Mumps Titer: Date: c) Rubella Titer: Date: d) Chicken Pox If yes, month/year: k) Sleepwalking i) Cough (persistent, recurring) j) Headaches (persistent, recurring) e) Poliomyelitis l) Enuresis f) Hepatitis m) Appendicitis g) Tuberculosis n) Parasites (internal) If yes, give detailed information and dates (use extra pages if necessary): YES NO 4 ACNE Yes No If yes, identify area, severity, any medication taken, name, dosage & frequency: 5 ALLERGIES Yes No If yes, identify type, any medication taken, name dosage & frequency: 6 ASTHM A Yes No If yes, identify type, severity, any medication taken, name, dosage & frequency: 7 DIABETES Yes No If yes, identify type, severity, any medication taken, name, dosage & frequency: 8 SEIZURE DISORDER Yes No If yes, identify type, severity, any medication taken, name, dosage & frequency: 9 HAS THE CANDI DATE EVER HAD ANY DISEASE, IMPAIRMENT OR ABNORMALI TY OF: YES NO a) Abdominal organs, digestive system e) Heart blood vessels b) Lungs, respiratory system f) Tonsils nose or throat c) Bones, joints, locomotor system g) Blood, endocrine system d) Genito-urinary system h) Eyes/vision, ear/hearing If yes, please explain (use extra pages, if necessary ) YES NO 10 HAS THE CANDI DATE BEEN HOSPITALIZED? Yes No If yes, give dates, diagnosis and outcome for each incident.

11 3b Health Certificate FOR OFFICE USE AFS ID# Candidate Name (First/Middle/Last) Home Country 11 Is the candidate currently taking medication or injections (other than those mentioned previously)? Yes No 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? Yes No 16 What was the date of the candidate s last dental check up? Does the candidate wear dental braces? Yes No If yes, will orthodontic care be needed while on the program? Yes No Frequency? 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 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 Signature Address 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:

12 ERGO Youth Exchange Parental Authorization Form CANDIDATE NAME HOME COUNTRY CONSENT The candidate application, is incorporated herein by reference and this consent form exclusively applies to the candidate application. I understand that my privacy is very important to AFS and that prior to participating in the inquiry application process in which any of my personal or sensitive information ( personal data ) may be collected, AFS would like to inform me about its data protection and privacy policies and obtain my permission. I understand and accept that AFS may process the personal and sensitive information that I have provided here, and may transmit such data to third parties for any purpose reasonably required for the proper organization and fulfillment of the AFS inquiry application process and the AFS program. I understand that the dataa will not be sold or otherwise transferred to third parties for purpose. AFS will transfer and store personal dataa in central databases in at least two locations to ensure that the data is not lost. Currently those locations are in the United States of America and in Thailand. Those databases have a restrictive access and can only be accessed by AFS employees or volunteers, both of which will use the information exclusively for the management of the AFS program operations. By signing below, you explicitly acknowledge that AFS Intercultural Programs, Inc., its national and regional affiliates and Partner organizations (herein referred to as AFS ) are entitled to process the personal data being provided by me (including all sensitive personal data being provided) in the manner described above. You also acknowledge and confirm that all provided personal data is accurate and complete. 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 AND FOR RELEASE OF MEDICAL INFORMATION 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. We hereby also 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. CANDIDATE NAME SIGNATURE PARENT/GUARDIAN 1 NAME* SIGNATURE PARENT/GUARDIAN 2 NAME* SIGNATURE DATE PLACE * Parent/Guardian signature is required for all secondary school programs and candidates not of legal age in the country of residence.