student application 2014 2015.docx · web viewbirthplace: click or tap here to enter text. ......

Global OutreachExecutive Director: Barbara Tota-Boryczka

4815 Whitetail WayAppleton, WI 54914

Phone: 920-540-3085 [email protected]

Spiritual Director: Fr. Larry Seidl [email protected]

2017-18 STUDENT APPLICATION Student Name: Click or tap here to enter text.

(TYPE: First Name (Given) / Middle Name / Family Name)

Application Instructions:

1. Carefully read the Mission Statement and Objectives of the Global Outreach (G.O.) Program, as well as the Student Rules and Standards of Conduct.

2. Applications should be done on the computer and typed. Applications submitted in handwriting will not be accepted.

3. Download all forms to your computer, complete the Application Form, and email as an attachment. You can email the Recommendation Forms and Medical Form to the appropriate persons. Instruct them to download them, fill them out on the computer, and print and sign them. Then they can scan them and email them directly to the email addresses at the top of the page, or send them to the address included.

4. Student and parent(s) signatures are required on the Signature Page. These will need to be printed and scanned, then returned WITH your application.

5. Print your application and bring the original signed sheets with you, if you are accepted into the Program.

6. Your responses to all questions should be thoughtful, truthful, and detailed. Space for your answers will adjust as you type.

7. Your letter to your host family is a very important part of your application. Take time to compose it with thought. It should be written in English without assistance from anyone else.

8. Applications should be e-mailed by you before January 15, 2017 to both directors at: barbar [email protected] and [email protected]. You may use PDF format.

9. Interviews take place in February. Candidates will be notified of results by the end of March. Once a Host Family has been found for you, an acceptance letter will be sent to you.

10. The Program fee is due by June 30, 2017 for accepted students.

11. The Liability Form and Insurance Forms are due two weeks after your acceptance letter. They will be sent to you at the same time as your Acceptance Letter.

To ensure that you have completed every step, please click on the boxes below, some will be on separate forms:

Application Contents:Document Page To be completed, read and/or signed by

☐ G.O. Mission, Vision, and Objectives p. 2 Student and Parent(s) / Guardian☐ Student Rules and Standards of Conduct p. 3-5 Student and Parent(s) / Guardian

2016-17 Student application – p.1

mailto:[email protected]






☐ Student Agreement –One Year Program p. 6 Student and Parent(s) / Guardian☐ Student Demographic Page p. 7 Student and Parent(s) / Guardian☐ Parent Information p. 8 Parent(s) /Guardian☐ Emergency contact p. 9 Student☐ School Information p. 10 Student☐ Student Application part I-III p. 11-15 Student☐ Student Letter to Host Family p. 16 Student☐ Student Photos p. 17-18 Student☐ Parent Questionnaire p. 19-20 Parent(s) /Guardian☐ Permission to Travel (On Signature Page) p. 23 Parent(s) / Guardian☐ Medical Information Form Licensed Physician

☐ Photocopy of Student Passport-make sure it is valid for the school year p. 21 Include with the application

☐ Transcripts from previous 2 years P. 22 Include English translation of transcripts☐ English Teacher Recommendation Form English Teacher☐ Class Teacher Recommendation Form Class Teacher☐ Headmaster Recommendation Form Headmaster or Principal☐ Pastor Recommendation Form Pastor or School chaplain

☐ Passport sized photo (approx. 1”x 1½”) p. 7 Attach one photo to page 7 of application

☐Liability Form, Student Insurance Coverage Form and photocopy of Medical Insurance policy are due two weeks after your acceptance letter is received. You will receive these forms with your Acceptance Letter.

E-mail after your acceptance for the program and bring the original to the 2017 GO Orientation in U.S.

The GLOBAL OUTREACH ProgramMISSION:Global Outreach is committed to the building of a civilization of love in Central/Eastern Europe as well as in the United States through the formation of young Catholic leaders who are committed to rebuilding the Church.VISION: Global Outreach achieves its mission by means of Catholic student exchanges between high school and other Church organizations in the U.S. and Central/Eastern Europe.

In addition to the values of cultural sharing and personal growth, Global Outreach encourages students to grow in their Christian faith and servant leadership abilities with a commitment to the vision of building a civilization of love. The program supports the students in their efforts to grow as persons, becoming healthier, wiser, freer, more autonomous and more likely to become servants, especially of those who are least privileged in society.

Global Outreach also seeks to promote links between Catholic leaders and institutions in Central/Eastern Europe and the U.S., helping them to grow in their efforts to build a civilization of love through the renewal of the Catholic Church and its commitment to the new evangelization.

THE GLOBAL OUTREACH PROGRAM OBJECTIVES:2016-17 Student application – p.2







Each student will attend a Catholic high school in the US for a full academic year (junior status) while living with a Catholic family. He/she will participate in school, parish, and community activities, especially youth ministry programs, and will share his/her culture, faith, and talents. Specific objectives for each student are:1. To successfully complete one academic year in an American Catholic high school, and we highly recommend that students

a. Participate in and successfully complete a course in speech, and develop good oral communication skillsb. Participate in and successfully complete English courses which encourage the development of a well-rounded use of the

English language, including grammatical usage, reading, writing, and interpersonal communicationc. Participate in and successfully complete a course in American Historyd. Participate and successfully complete the required Religious Studies coursee. Participate in the school’s campus ministry program and, if possible, a Teens Encounter Christ (TEC) weekendf. Share and participate in at least one school extracurricular activityg. Sign up for and successfully complete one or more other courses for enrichment which might not be part of the

curriculum back home

2. To learn about, adapt to, and participate in an American Catholic Christian family’s life and activitiesa. Participate in parish life through available activities, such as choir, youth groups, festivals, child care, and liturgical

ministryb. Participate with their families in community activities such as community projects, holiday celebrations, and volunteer

opportunities, and become familiar with their surroundings, ex. public transportation, shops, areas of interest, etc.

3. To share their native culture, their faith, and their individual talents with their host families, schools, and parish and civic communitiesa. Examples are: speaking in classrooms and at parish and club meetings; participating in cultural fairs; talking with

individuals; using musical, theatrical, and leadership talents; participating in retreats; and sharing information about the Global Outreach program

4. To return to their countries with an intent to participate in parish and community as Christian servant leadersa. Participate in and provide leadership at the Global Outreach Summer Camp during the summers, both prior to the

exchange and immediately following the student’s return home from the United States b. Other examples are: being active in youth organizations; encouraging others to participate in Global Outreach;

participating in alumni activities in the Global Outreach program; sharing their understanding of American culture as expressed in family life, parish life, schools, and civic organizations; volunteerism; and active participation in their parishes

Student Rules and Standards of ConductGlobal Outreach expects the highest standards of behavior from students at all times. In turn, the Board of Directors and

staff of Global Outreach work together to ensure that the student’s exchange experience in the United States is as safe, successful, and enriching for both students and host family as possible. The following Student Rules and Standards of Conduct have been established for that purpose. Violation of these rules will lead to disciplinary action and possible return of the student to his/her home country. Violations of local, state, or federal laws or serious misbehavior in the host family or the community will result in an immediate return to the home country. A student’s return home will be at the expense of the student’s natural parent(s) or guardian(s), with no refund of program fees.

LOCAL, STATE, and FEDERAL LAWS:1. The student in the Global Outreach program is not permitted to purchase, possess, or consume any alcoholic beverages.

Drinking alcoholic beverages, including beer and wine, is illegal for persons under the age of 21.2. Smoking or chewing, as well as purchase or possession of tobacco products, is not permitted for any participant of the Global

Outreach program at any time.3. The student must not buy, sell, possess, or use illegal drugs of any kind. If the student is taking prescription drugs, the name,

dosage, and length of time of use for each drug must be listed on the Global Outreach Medical Form. The student must not 2016-17 Student application – p.3







associate with any person who engages in any illegal activity, such as drug use and trafficking and/or underage alcohol consumption.

4. Students are prohibited from accessing, purchasing, possessing and/or viewing pornography or other obscene materials.5. The student must not commit or take part in any act of violence against another person or property.6. It is illegal for the student to take regular employment while in the U.S. The only exceptions are occasional odd jobs, such as

yard work or baby-sitting. Any such jobs must not interfere with activities or objectives of the Global Outreach program, and students must have host family permission.

7. Because of the danger and liability involved in driving, the student may not drive any motorized vehicle. This includes, but is not limited to, any car, truck, motorcycle, All-Terrain Vehicle (ATV), boat, farm equipment, snowmobile, etc. In addition, the student may not obtain a U.S. driver’s license. The student must wear his/her seatbelt and shoulder harness whenever riding in an automobile.

8. The student is forbidden to hitchhike at any time, either alone or with companions. It is illegal in most states and extremely dangerous.

YOUR HOST FAMILY:All Global Outreach host families are volunteers and receive no compensation for hosting a G.O. exchange student. Host

families participate in the Global Outreach program because of their sincere desire to share their Christian faith and family life, and to experience other cultures. Host families agree to provide students with a bed and meals and welcome them as a member of their family. The student is not guaranteed a private bedroom, nor placement within a particular community or school.

9. The student will regard his/her host parents as his/her own, and will respect them and their home in every way. The student will not be staying as a guest in the home, but rather as a family member, and will be expected to comply with all rules of the host family, including curfews, visitors, chores, etc., as is proper and usual in the United States.

10. The student must receive permission from the host parents to use any device belonging to the host family, such as the telephone, computer, or television. The student must adhere to any rules and time restrictions set on using such devices.

11. The student is responsible for to pay for all phone calls he/she makes outside the local calling area. We highly recommend that students purchase and use prepaid phone cards to use for their long-distance calls.

12. The student must receive permission from host parents for any and all activities. The student must keep the host family informed at all times of his/her whereabouts, with whom he/she is associating, and time of departure from and return to the host family’s home.

13. The student must not borrow money from the host family or from any other source. Natural parents must supply the student with an adequate amount of spending money, normally $100 per month. Students are responsible for all extraordinary expenses, such as non-essential school supplies, entertainment, meals outside of the home, personal expenses, and travel expenses within the United States. The student will establish a bank account separate from that of his host family.

14. As a responsible Catholic young adult, the student will observe the laws of the Church, including, but not limited to, weekly attendance at Mass.

ACADEMIC LIFE:A student’s strong academic performance will foster continued support of the Global Outreach program in the host

communities and future placement of Global Outreach students. Students are expected to participate actively in academics and extracurricular activities, and display a respectful and appreciative Christian demeanor both in and outside of school.

15. The student will be enrolled in his/her school as a junior. Since the student will not have met the (four-year) requirements for graduation from a high school in the United States, he/she will not receive a diploma nor will he/she graduate from the high school. Depending upon school policy, the student may receive a certificate of attendance from the school.

16. The student must attend school daily, maintain a full course load, and obey all school rules and regulations, including dress code and appropriate behavior. The student may not take time off from school except in case of illness or emergency, or by prior written approval by the Director of Global Outreach for a special event.

17. The student is responsible for all extra school fees, such as yearbook, class photos, student activities, sports equipment, entertainment, etc.








18. Disruptive behavior, academic failure, or breaking of school rules will be grounds for the student to be sent home at his natural parents’ expense.

19. The student may not play varsity sports; however, he/she is encouraged to try out for and become involved in intramural and/or junior varsity sports. Placement on a team is not guaranteed but is at the discretion of the high school.

VISITORS AND TRAVEL: 20. Visits from members of the student’s natural family from his/her home country can be very disruptive to the student’s

adjustment to his/her exchange experience, as well as an inconvenience to the host family. Therefore, visits are not recommended until the very end of the program, when the student may arrange to travel back home with his/her natural family. Any visit must be by (prior) invitation of the host family and must have prior approval by the Executive Director.

21. Likewise, the student is strongly discouraged from visiting relatives residing in the United States for the first six months of their exchange. Written permission from the natural parents, permission of the host family, and a letter of invitation from the family with whom the student wishes to visit, are required prior to any visit. Final permission for the visit is at the sole discretion of the Director of Global Outreach.

22. The student may not travel back to his/her home country during the exchange. In case of family emergency, the student should contact the Director of Global Outreach for further instruction.

23. The student may not travel outside his/her local community, either by him/herself or with peers, unless he/she has the permission of the host parent(s).

24. Out-of-state travel with the host family, another family, an approved group (such as a school or church-sponsored group approved by Global Outreach), or with a responsible adult is permitted only with prior approval from the host family. The host family and Global Outreach must be provided with pertinent information about the trip and contact information in case of emergency.

25. The student must carry his/her passport whenever traveling by air. If the student wishes to travel with his host family outside of the United States, he/she must have written permission from his/her natural parent(s) or guardian and Director of Global Outreach. Before departing for such a trip, the student must check with U.S. Immigration to be sure that he/she will be allowed to re-enter the United States.

RETURNING HOME:26. The student is not allowed to remain in the United States at the conclusion of the exchange program (one-to-two weeks after

the end of the academic year) unless prior permission is given in writing by the student’s natural parents and the Global Outreach Board of Directors for adult-supervised travel. A detailed itinerary of travel plans, including modes of travel and all contact information during the travel, must be submitted. The student must maintain adequate insurance coverage.

27. The student MUST depart the United States prior to the expiration of his/her visa. Students who do not leave the country as noted above, will be reported to the Bureau of Citizenship and Immigration Services as required by law.

28. The Global Outreach program is for one year only and does not allow a second year of study in the United States for any reason.

29. The rule of the program is to fulfill one year of study in the United States and return after that year to home country to complete gymnasium/high school education, to share experience as a Global Outreach student with local church, school and country, and to promote the Global Outreach program in those places. Therefore, student will not ask the Global Outreach staff and board to extend his/her stay in the United States for an additional year or years of study and will not make any attempts to persuade Global Outreach partner school in the United States to extend studies beyond the one year.

MISCELLANEOUS:30. The student must respect and obey all rules and decisions made by the Global Outreach Board of Directors. Failure to do so

may result in the student being sent home at his/her natural parent/guardian’s expense, with no refund of program fees.








STUDENT AGREEMENT– ONE YEAR PROGRAMThe Global Outreach program is for one year only and that the program does not allow a second year of

study in the United States for any reason whatsoever. You must agree to accept and support this rule of the program by fulfilling my one year of study in the United States and returning after that year to your home country to complete your gymnasium/high school education, to share your experience as a Global Outreach student with your church, school and country, and to promote the Global Outreach program in those places. You must promise that you will not ask the Global Outreach staff and board to extend your stay in the United States for an additional year or years of study. You must further promise that you will not make any attempts to persuade your school in the United States to extend your studies beyond the one year that it has already agreed to grant you.

Please understand that this promise does not deny you the opportunity to return to the United States for college or university studies after your graduation from gymnasium/high school should you desire to do so.








STUDENT APPLICATION FORM

Name (First, Middle, Family): Click or tap here to enter text.

Name you are commonly called: Click or tap here to enter text.☐ Male ☐ Female Date of Birth: Click or tap here to enter text. (Month Write a word, not a number / Day/ Year

Example: January 1, 2017)

Your age when you enter the U.S. to begin the program: Click or tap here to enter text.

Years/Months

Address as it should appear on correspondence:

Click or tap here to enter text.Street / Number / Postal Code / City

Click or tap here to enter text.Country

Home telephone: Click or tap here to enter text. City code / Home number

Your cell-phone: Click or tap here to enter text. City code / Cell number

Your email address: Click or tap here to enter text.

(This email address must be current as G.O. will communicate with you primarily via email.)

Insert Recent Photo

Have you applied to any other exchange program(s) for the coming academic year? ☐ No ☐ Yes Were you accepted? ☐ No ☐ Yes If yes, which one(s)? Click or tap here to enter text.

Birthplace: Click or tap here to enter text.

City / CountryCitizenship: Click or tap here to enter text.

Country issuing passport: Click or tap here to enter text.

Passport number: Click or tap here to enter text. Expiration date: Click or tap here to enter text.

(Month write as a word / Day / Year)

Height: Click or tap here to enter text. Weight:Click or tap here to enter text. Eyes: Click or tap here to enter text. Hair: Click or tap here to enter text.








PARENT INFORMATION

Father or Legal Guardian

Last Name: Click or tap here to enter text.First Name: Click or tap here to enter text.Middle initial: Age: Click or tap here to enter text.

Address:Street: Number:Click or tap here to enter text.

Postal Code: City: Click or tap here to enter text.

Country: Click or tap here to enter text.

Home telephone: Click or tap here to enter text.

Cellphone: Click or tap here to enter text.

Email: Click or tap here to enter text.

Occupation/Profession: Click or tap here to enter text.

Work telephone: Click or tap here to enter text.

Work email: Click or tap here to enter text. Religion: Click or tap here to enter text.

Mother or Legal Guardian

Last Name: Click or tap here to enter text.First Name: Click or tap here to enter text.Middle initial: Age: Click or tap here to enter text.

Address:Street: Number:Click or tap here to enter text.

Postal Code: City: Click or tap here to enter text.

Country: Click or tap here to enter text.

Home telephone: Click or tap here to enter text.

Cellphone: Click or tap here to enter text.

Email: Click or tap here to enter text.

Occupation/Profession: Click or tap here to enter text.

Work telephone: Click or tap here to enter text.

Work email: Click or tap here to enter text.

Religion: Click or tap here to enter text.

I currently live with: ☐ Father ☐ Mother ☐ Stepfather ☐ Stepmother ☐ grandparent(s) ☐ sibling☐ other Click or tap here to enter text.

Names of all persons living in your home:

Age Gender Living at home? Relationship(Parent, brother, etc)

Click or tap here to enter text. Click or tap here to enter text. ☐M ☐F ☐Yes Click or tap here to enter text.





Click or tap here to enter text. Click or tap here to enter text. ☐M ☐ F ☐Yes Click or tap here to enter text.











Emergency Contact :

Name: Click or tap here to enter text.

Relationship: Click or tap here to enter text.

Address: Click or tap here to enter text.

Home Phone: Click or tap here to enter text.

Work phone: Click or tap here to enter text.

List any relative(s) living in the United States:

Name: Address: Phone:

Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text.










SCHOOL INFORMATION

School currently attending:

School Name: Click or tap here to enter text.

School address as it should appear on correspondence:

Click or tap here to enter text. Click or tap here to enter text.

Street / Number Click or tap here to enter text. Click or tap here to enter text.

Postal Code / CityCountry: Click or tap here to enter text.

Phone: Click or tap here to enter text.

City code / Number

Anticipated graduation date: Click or tap here to enter text.

Month/Year

Total years of school completed: Click or tap here to enter text.

Your current year in school: U.S. equivalent: ☐9 ☐10 ☐11 ☐12

Headmaster /Principal Name: Click or tap here to enter text.

Class Teacher Name: Click or tap here to enter text.

English Teacher Name: Click or tap here to enter text.

Pastor/Chaplain Name: Click or tap here to enter text.








STUDENT APPLICATION

PART I:Click on the box ☒ to check the following words that best describe you:

☐ Serious☐Polite☐Optimistic☐ Calm☐Friendly☐Sensitive☐ Faith-filled☐Talkative☐Appreciative

☐Shy☐Quick-tempered☐Casual☐Neat☐Spontaneous☐Adaptable☐Helpful☐Humorous☐Giving

☐Responsible☐Emotional☐Reserved☐Formal☐Active☐Quiet☐Observant☐Thoughtful☐Tolerant

☐Traditional☐Informal☐Compassionate☐Adventurous☐Patient☐Insecure☐Open☐Cheerful☐Independent

Your responses to all questions should be thoughtful, truthful, and detailed. Space for your answers will be added as you type.

1. How did you learn about the Global Outreach Program? Please include names of any alumni, teachers, family

members or friends who told you about the program. Click or tap here to enter text.

2. Do you have any special dietary needs (e.g. vegetarian, etc.)? ☐ No ☐Yes If yes, please explain: Click or tap here to enter text.

3. What kinds of activities do you generally do with your family? Click or tap here to enter text.

4. What household chores and/or responsibilities do you have as a member of your family? Click or tap here to enter text.

5. Do you sing and/or play a musical instrument? ☐ No ☐ Yes If yes, which one(s)? Click or tap here to enter text.

6. Choose five favorite interests in order of preference with “1” being most preferred:2016-17 Student application – p.11







Billiards/pocket pool Computers Discussing ideas Music-classical Singing Board games/cards Cooking Discussing politics

Music-contemporary Social dating Crafts Drama/theater Photography/video Stamp/coin collecting Camping/backpacking Dance-ballet

Drawing/painting Playing an instrument

Watching television Chess/backgammon Dance-modern/jazz Gardening Reading Watching sports

Cinema/movies Dance-social/ballroom Museums/galleries Sewing/needlework Scouting Other: write in space below

1. Click or tap here to enter text.





7. Indicate four favorite sports in order of preference by using the numbers with “1” being most preferred.

U.S. football Field hockey Horseback riding Sailing Tennis Badminton Fishing

Roller-skating Roller-blading Track/running Baseball Golf Ice Hockey Snow skiing

Snow boarding Volleyball Basketball Gymnastics Ice-skating Soccer Water skiing

Bicycling Hiking Martial arts Swimming Windsurfing Other (specify): Click or tap here to enter text.





8. Describe your membership in clubs or organizations, if any. Click or tap here to enter text.

9. What is your religion? Note: Only practicing Catholic students can be part of the Global Outreach Program.

Click or tap here to enter text.

10. How often do you attend Mass on Sunday? Click or tap here to enter text.

11. How often do you attend Mass during the week? Click or tap here to enter text.

12. Have you received the sacrament of Confirmation? Click or tap here to enter text.








13. If you have not been Confirmed, are you planning to receive the sacrament? Do you have plans to prepare for Confirmation and if so, what are they?Click or tap here to enter text.

14. Please describe what you do for your prayer life outside of Mass. (Daily prayer, retreats, participation in spiritual communities etc.) Click or tap here to enter text.

15. Describe your involvement in parish activities, if any. Click or tap here to enter text.

16. Describe any volunteer activities in which you have participated in the previous two years, if any. Click or tap here to enter text.

17. Describe any job or work experience you have had in the previous two years. Click or tap here to enter text.

18. List any special recognition and/or awards you have received for your activities, if any (not academic awards). Click or tap here to enter text.

19. In what activities would you like to be involved with your host family and/or in school during your exchange? Click or tap here to enter text.

20. Have you received any academic awards or honors, and/or have you had any outstanding achievements? Please describe. Click or tap here to enter text.

21. When you return to your home, what are your plans for your future? Click or tap here to enter text.

22. Describe your previous experience(s) away from home, without your family, if any. Click or tap here to enter text.

PART II:

Foreign Languages Spoken and/or Studied:

Language Years of Study Proficiency

Fair Average Good Excellent Fluent

English Click or tap here to enter text.

☒ ☐ ☐ ☐ ☐Other languages Years of Study Fair Average Good Excellent Fluent


☐ ☐ ☐ ☐ ☐









☐ ☐ ☐ ☐ ☐Click or tap here to enter text. Click or tap here

to enter text.☐ ☐ ☐ ☐ ☐

PART III: Please take the time to carefully consider each question below, and answer as completely as possible.

23. Give your three most important reasons why you chose to apply to the Global Outreach Program.




24. What qualities and/or personality traits do you most value in yourself, and why? Click or tap here to enter text.

25. What is your most important accomplishment so far? Why was it important to you? Click or tap here to enter text.

26. What experiences have you had that demonstrate your adaptability and flexibility in new situations? Click or tap here to enter text.

27. What do you expect to gain from your exchange experience? Click or tap here to enter text.

28. How would a host family benefit by having you as an exchange student in their home? Click or tap here to enter text.

29. What are the unique gifts that God has given to you? Click or tap here to enter text.

30. In what ways do you expect that you will use your gifts as a student of the Global Outreach Program? Click or tap here to enter text.

31. What are the most important challenges or problems facing the Catholic Church in your country? Click or tap here to enter text.

32. How do you feel your society and culture differs from American society and culture? Click or tap here to enter text.

33. What will you do if your ideas are different from those of your host family? Click or tap here to enter text.

34. At some point, most exchange students feel lonely and homesick. How will you handle those feelings? Click or tap here to enter text.

35. What will you do to prepare yourself to live for a year in the U.S.?








STUDENT LETTER TO HOST FAMILYYour letter is a very important part of your application, as it is your opportunity to reveal your personality. Your host family is interested in learning about you in order to prepare for your stay with them. Please describe yourself and your family. Tell why you want to participate in the Global Outreach program in the United States, and what you expect to learn. Include interests and activities you would like to share with your host family during your stay. Make your letter friendly and personal. This is also a good time to express your appreciation in advance for being invited to become a member of their family. Your letter should be approximately one page in length, and written by you with no assistance from anyone else. Please type on computer.Click or tap here to enter text.








STUDENT PHOTOSAttach three recent, small photographs of yourself in your home with your family, you with friends, and you in your community. These will help your host family understand what your life is like in your home country. Describe each photo in the space provided.









Parent QuestionnaireThe following questions are to be completed by the parents. This does not need to be written in perfect English – the content is most important. Along with your child’s letter to the host family, this information will have much influence on our decision to accept your child into the program and place him/her with a host family. Please provide detailed information that will help us to understand your child's personality, background, lifestyle, and habits. We ask that you be very frank and honest. Remember that you are writing to another parent, as well as to the Global Outreach staff. Please include information you would want to know if you were going to host their child.Thank you.

1. Who in the family initiated the idea of an exchange with Global Outreach?Click or tap here to enter text.

2. What responsibilities (curfew, chores, behaviors, etc.) does your son/daughter have at home as a member of your family? Click or tap here to enter text.

3. Do you have any restrictions on your son/daughter in regard to social activities?Click or tap here to enter text.

4. Please describe your son/daughter’s personal qualities and characteristics. Click or tap here to enter text.

5. What are his/her personal strengths? Click or tap here to enter text.

6. What are his/her weaknesses and areas in which growth is needed?


7. How does he/she cooperate with authority at home, in school and elsewhere?Click or tap here to enter text.

8. How does your son/daughter express anger and/or frustration?Click or tap here to enter text.

9. How does your son/daughter handle problems?2016-17 Student application – p.19








10. What are the hopes and/or expectations you have for your child and his/her exchange experience?Click or tap here to enter text.

11. Please describe the depth of your child’s faith. How does he/she display the quality of his/her faith commitment (e.g. prayer life, service of others, church attendance, etc.)?Click or tap here to enter text.

12. Please describe other information about your child that will help his/her host family to prepare to welcome and care for him/her as a member of their family.Click or tap here to enter text.

Name of Parent/s who responded to the above questions:

Click or tap here to enter text. Click or tap to enter a date.

Click or tap here to enter text. Click or tap to enter a date.








Copy of your valid Passport (page with your picture)

In addition, please scan and email your visa when you have it or bring to orientation. Make sure the passport is not expired or will expire before you leave.

Student Application p.21







Certificate with your grades from previous two years.

Please include English translation

Scan and email previous year’s grades, 2015-16. Scan and email this year’s grades, 2016-17 by JULY 1, 2017.








Signature Pages

Important: Please click in each of the boxes, stating that you have read, understand, and agree with the information contained on those pages of the Global Outreach Student Application Form, that you have completed. Print the page and sign. After completing the required signatures, scan this page, and include it with your application form. Bring the original with you.

☐ We have read and we understand the Mission, Vision, and Objectives of the Global Outreach program on Page 2 of the Student Application Form.

☐ We have read and we understand the Global Outreach Student Rules and Standards of Contact on Pages 3 and 4 of the Student Application Form.

☐ We have read and we understand the Student Rules and Standards of Conduct for the Global Outreach program. Furthermore, we understand that by submitting this application to Global Outreach, we agree to support all objectives of the Global Outreach program, abide by their Rules and Standards of Conduct, and fully participate in all required program activities, including the Summer Camps prior to and immediately following the year of exchange.

☐ We understand that the Global Outreach program is for one year only and that the program does not allow a second year of study in the United States for any reason whatsoever as described on Page 5 of the Student application form.

☐ Permission to Travel: As the legal parents/guardians of the student applying for the Global Outreach Program, we herewith give our full consent for our son/daughter to travel within the United States if accompanied by an adult person approved by Global Outreach (over age 25), or with an approved organization such as a church or youth group, or together with his/her host family. We understand that any travel without the host family must be approved in writing by the host family, and a complete itinerary is to be provided to them. We further understand that our son/daughter will be responsible for any expenses incurred during any trip or excursion. Our son/daughter may not travel while school is in session unless the trip is approved by Global Outreach. (Parent’s signature and approval is required even if the student is over 18 years of age.)

Student’s Signature: _________________________________________ Date: ____________________

Mother’s /Guardian’s signature: ___________________________________________ Date: _____________________

Father’s/Guardian’s Signature: ___________________________________________ Date: _____________________




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