(YES) Program PRE-APPLICATION for 2015-2016

Kennedy-Lugar Youth Exchange and Study (YES) Program
PRE-APPLICATION for 2015-2016 Academic Year
Instructions:
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Answer ALL of the questions from the sections below in English. INCOMPLETE applications will NOT be
considered.
Provide a certified copy of the last three years official transcript of school grades.
Provide a birth certificate.
Provide an official high school registration form.
Provide a current passport-size photo.
Applicants can submit the application online to [email protected], deliver it in person to
AMIDEAST Tunis or Sousse, send it through the school, or mail the application to the following address as
follows:
YES Program 2015
AMIDEAST – Tunis
22 rue Al Amine Al Abassi
Cite Jardins – 1002 Tunis
Tel: 71.145.745 Fax: 71.145.701
STUDENT DATA
Last Name: _______________________________ First Name: ________________________________
Sex:
 Male
 Female
Date of birth:
/
/
City of birth:
Day Month
Year
Country of Birth: ______________________________________________________________________
Citizenship: __________________________________________________________________________
Are you a U.S. citizen?
 YES
 NO
Do you have legal permanent residence status (green card) for the U.S., hold a U.S. residency visa or have a green
card application currently pending? Yes No
Does your father or mother hold a U.S. employment visa or have an application for legal permanent residence status
(green card) currently pending?
 YES
 NO
Do you have a Tunisian Passport?
 YES
 NO
Permanent Address: __________________________________________________
City: _____________________________ Zip Code: ___________________________
Country: ___________________________
Home Phone: ________________________________________________________________________
Mobile: _____________________________________________________________________________
Fax: ________________________________________________________________________________
E-mail Address: ______________________________________________________________________
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PHYSICAL IMPAIRMENT
The YES Program does not discriminate on the basis of race, color, religion, sex, national origin, and/or physical
impairment. Please describe any physical impairment you might have, including any special equipment or medical
treatment you require.
FAMILY DETAILS
Father’s Data:
Last Name: ________________________ First Name: ________________________
Occupation: __________________________________________________________________
Phone: ______________________________________________________________________
Mother’s Data:
Last Name: ________________________ First Name: ________________________
Occupation: __________________________________________________________________
Phone: ______________________________________________________________________
Family Details:
Student lives with:
 Both Parents
 Mother Only
 Other
Please give more details if you answered ‘other’:
Parents are:
 Married
Father Only
 Divorced
Family Members:
Relation to you
Full Name
Gender
Age
Current Occupation*
Member 1
Member 2
Member 3
Member 4
2
Member 5
Member 6
*If student, please mention which grade.
Please attach a separate document if you need more space
Do you have a family member who participated in the YES program?
 YES
 NO
If yes, please provide the Full Name: _________________________________________________
Did you participate in the English Access Microscholarship Program?
 YES
Teachers Name:
________
 NO
EDUCATION
School Name: ______________________________________________________________________
School Director’s Name: ______________________________________________________________
School Address: _____________________________________________________________________
School Telephone: ____________________________________
Type of School:
PUBLIC
PRIVATE
Student’s Current grade level: ___________________________________________________________
Student’s Last year’s Grade Average ______________________________________________________
Number of Years of English Study: _______________________________________________________
Last year’s English Grade Average________________________________________________________
INTERESTS AND HOBBIES – To be completed by student
List all school and extracurricular activities and hobbies in which you have participated.
Start with the most recent:
Activity
Number of
Hours/Week
Month/Year
Started
Month/Year
Ended
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Have you received any awards, or do you have any outstanding achievements in the activities listed above?
Name of Award/Achievement: ___________________________________________________________________
Reason for receiving award: _____________________________________________________________________
____________________________________________________________________________________________
Date received: ___________________________________________________________________
Are there any activities you would especially like to pursue or learn while being an exchange student in the
U.S.?
FUTURE PLANS
Do you intend to continue your education upon completion of secondary school?
 YES
 NO
If yes, please provide where _________________________________________________
What do you intend to study?
What are your career plans?
HOW DID YOU LEARN ABOUT THE Kennedy-Lugar YES SCHOLARSHIP? (Check ALL that apply)
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Radio Ad: (if yes, which one(s)?) _________________________________________________
School
Newspaper: (if yes, which one(s)?) _______________________________________________
Facebook
TV Show: (if yes, which one(s)?) _________________________________________________
Previous YES student(s)
Website Ad: (if yes, which one(s)?) _______________________________________________
AMIDEAST Website
YES Program Brochure/Application
U.S. Embassy Website
Other (please describe):
______________________________________________________________________________________
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SHORT ESSAYS
Please answer the following question on a separate sheet of paper. There is no "right" or "wrong"
answer - only information that will help us to understand you better as an individual.
Please answer the following questions thoroughly (Write a minimum of 200 words for each question).
1. Why do you want to participate in the YES program?
2. What are the problems or challenges (other than language) that you think you might encounter
while in the US. What would you do to solve and overcome them?
Parent’s Consent— To be completed and signed by parents.
My son/daughter has my permission to apply for, and to participate in the YES Program administered by
AMIDEAST.
.‫ ابنتي لتقديم طلب والمشاركة في برنامج منح التي تديرها االمديست‬/‫اوافق بمشاركة ابني‬
Parent/Guardian’s signature:
Date:
DEADLINE FOR APPLICATIONS DIRECTLY TO AMIDEAST TUNIS/SOUSSE IS December 12th, 2014
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