Student Application Program Description: The Pan Africa Youth Leadership Program (PAYLP) is a three-week exchange from dates if known in the United States for high school students and adult mentors. The primary program themes are civic education, community service, entrepreneurship, and youth leadership development. Participants live with host families for the majority of the exchange and engage in leadership and civic education workshops, community service activities, visits to local schools and community organizations, project planning and development, and local cultural activities with American peers. Participants return home with action plans to bring their exchange experience to their home communities in the form of a wide range of community service projects.
Eligibility requirements: Be a citizen or legal resident living in South Africa (applicants with dual U.S. citizenship will not be considered) Be between 15 and 18 years old by [April 6,2024] and be able to attend at least one additional semester of high school in their home community. Have proficiency in English (Anglophone program) / French (Francophone program); Demonstrate good academic performance, an interest in community service and volunteer activities, leadership potential, good communication, and a positive attitude. Work cooperatively in a team setting and appreciate the opinions of others. Have permission from parent(s) or legal guardian(s) to participate in the program.
We encourage people with disabilities and from other diverse backgrounds to apply. Opportunities are open to people regardless of their race, color, national origin, sex, religion, socioeconomic status, disability, sexual orientation, or gender identity.
Instructions for completing this application: Fill out the application and answer all questions carefully and completely. The information you provide on this application will provide the basis for selecting participants for this program. Semi-finalists will be contacted for a [video call] interview.
There is no application fee. The U.S. Government will pay for all costs to participate in the program, including international travel to and from the United States, passport fees, orientations, and the exchange activities in the United States, including meals and lodging.
Youth Leadership Program – Student Application
This application is free of charge and may be duplicated. 2
Pan Africa Youth Leadership Program
Student Application
PERSONAL INFORMATION
Name_________________________________________________________________________ Last (Family) First Middle Current Address: ________________________________________________________________ City, State, Postal Code___________________________________________________________ Mailing Address (if different you’re your current address):_______________________________ City, State, Postal Code___________________________________________________________ Home Phone _______________________________Mobile Phone________________________ Email _________________________________________________________________________ Date of Birth (mm/dd/yyyy) _________________Age at the time of application: ___________ City and Country of Birth _________________________________________________________ Country of Citizenship or Permanent Legal Residence___________________________________ Do you have dual citizenship? [ ] Yes [ ] No If yes, indicate countries where you are a dual citizen: ____________________________ Gender: [ ] Male [ ] Female [ ] Other/Prefer to Self-Describe: ______________ Have you ever participated in an exchange program sponsored by the U.S. Department of State? [ ] Yes [ ] No If yes, provide the name of the program and date you participated: _________________
PARENT/GUARDIAN INFORMATION **Your parent or guardian must sign the application at the end** Parent/Guardian 1 Name ________________________________________________ Relation to you ___________ Address (if different from yours) _____________________________________________________ Phone _________________ Email ________________________ Occupation______________ Parent/Guardian 2 Name ________________________________________________ Relation to you __________
Youth Leadership Program – Student Application
This application is free of charge and may be duplicated. 3
Address (if different from yours) ___________________________________________________
Phone _________________ Email ________________________ Occupation______________ PASSPORT INFORMATION Do you have a valid passport? [ ] Yes [ ] No If yes, please attach a copy of your passport to your application. You do not need to currently possess a passport in order to submit your application to the program. However, please be advised that a passport, valid for 6 months after the program end date, is required for participation. If selected, the program will cover your costs to obtain a passport if you don’t already have one.
Full name as on your passport_____________________________________________________
Passport Number __________________________ Expiration Date (mm/dd/yyyy)__________ Issuing Country ____________________________
TRAVEL INFORMATION Have you ever traveled to the United States? [ ] Yes [ ] No If yes, please provide a brief description of dates, length and nature of your stay(s), and whether you obtained a visa: _____________________________________________________________________________ _____________________________________________________________________________ Have you ever traveled outside of your country? [ ] Yes [ ] No If yes, please provide a brief description of dates, length and nature of your stay(s): _____________________________________________________________________________ _____________________________________________________________________________
ACCOMMODATIONS
It is the goal of the Pan Africa Youth Leadership Program and its partners to ensure the full and equal participation of everybody regardless of gender, race, sexual preference, disability, or otherwise. It is our policy to make necessary, reasonable accommodations to ensure that our programs are accessible.
Youth Leadership Program – Student Application
This application is free of charge and may be duplicated. 4
Would you require a reasonable accommodation, as a result of a physical or mental
impairment, to enable you to access the full benefit of this program? [ ] Yes [ ] No If yes, use this space below to describe accommodations that could support you on program: ______________________________________________________________________________ ______________________________________________________________________________ EDUCATION AND ACTIVITIES School name___________________________________________________________________ School type (public, private, other)__________________________________________________ School address__________________________________________________________________ City, State, Postal code___________________________________________________________ Current grade _____________ Month and year you will graduate______________________ Academic subjects you are most interested in _______________________________________ _____________________________________________________________________________ Future studies and/or possible occupations you’ve considered _________________________ _____________________________________________________________________________ Please list all extracurricular or volunteer activities you currently take part in. Include how long you have been involved with each, and any awards or honors. Examples: school clubs, sports teams, youth organizations, community service activities, leisure time activities. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ LANGUAGE What is your native (maternal) language? If you are bilingual, please list both of your native/maternal languages________________________________________________________
Youth Leadership Program – Student Application
This application is free of charge and may be duplicated. 5
List other languages you have studied below.
Language_____________________________Number of years studied_______________ Language_____________________________Number of years studied_______________ SHORT ESSAYS: Please respond to the following short essay questions in one paragraph
What motivates you to apply to the Pan Africa Youth Leadership Program? How will your participation in the program help you address the issues currently facing your community?
In what ways are you an effective leader? Describe how you are a leader in your school, community, or home.
During this exchange, participants will act as ambassadors for their countries. What qualities do you have that would help you fulfill this role?
Upon your return home, you are asked to implement a community service project individually or in a small group. What idea(s) do you have for a project that would improve your community?
Youth Leadership Program – Student Application
This application is free of charge and may be duplicated. 6
PARTICIPANT AGREEMENT/PARENTAL CONSENT
By signing below, I verify that all the information in this application is true. I agree that if chosen to participate, I will participate in ALL program activities in the United States and South Africa, including the pre-departure orientation and follow-on activities. I also understand that I must remain with the program throughout the entire exchange and that personal travel within the United States during the program is not permitted.
Please note that the safety of participants and our communities is our number one priority. In- person exchange is contingent upon the continued stabilization of the pandemic and the safety of travel.
_____________________________________________________________________________ Applicant Signature Date
I permit my child to apply for and, if selected, to participate in this program.
_____________________________________________________________________________ Parent/Guardian 1 signature(s) Date _____________________________________________________________________________ Parent/Guardian 2 signature(s) Date
Youth Leadership Program – Student Application
This application is free of charge and may be duplicated. 7
REFERENCE FOR THE PAN AFRICA YOUTH LEADERSHIP PROGRAM
Applicant Name ____________________________________________________________
For the Applicant: Please submit [two] references with your application. The forms should be from a teacher [or] adult leader at an organization where you have volunteered or held a position of leadership or active membership, or other adult outside your family who knows you well. The form needs to be in English. You may submit this form with your application to [email protected]
For the Reference: The student named above is applying to take part in the Pan Africa Youth Leadership Program, a three-week exchange program in the United States. The selected students will be in a challenging academic environment and intensive leadership training. To succeed, the participants must be highly motivated, and be able to adjust to living and working with people of different social and cultural backgrounds. We value your honest assessment of the applicant in helping us select the most appropriate participants. If you would like to add additional comments, we encourage you to do so. Your answers will remain confidential.
Please indicate your opinion of this applicant’s ability to meet the challenges of this program. _____ I strongly recommend this student _____ I recommend this student _____ I have minor reservations about recommending this applicant _____ I have major reservations about recommending this applicant _____ I do not recommend this student
How long, and in what context or capacity, have you known this applicant?
What are the applicant’s strengths?
What are the academic or personal areas in which this applicant needs improvement?
Please describe the applicant’s behavior or attitude with respect to authority, peer relationships, responsibility, and work activities.
How do you think the applicant would adapt to unfamiliar environments and new situations?
Name (printed) _________________________________________________________________
