SOUTHEAST ASIA YOUTH LEADERSHIP PROGRAM
STUDENT APPLICATION FORM
Instructions for completing this application: Please fill out the application as completely as
possible, in English and bold. The information you provide on this application will provide the
basis for selecting semi-finalists for this program. Answer the questions carefully and
completely.
ABOUT YOU
Last Name:
First Name:
Middle Name:
Date of birth (MM/DD/YYYY):
Gender:
Address:
Mobile Phone:
Email:
City and Country of Birth:
Country of citizenship or permanent legal residence:
ABOUT YOUR FAMILY
Parent or guardian name(s):
Address (if different from yours):
Mobile phone:
Email:
Occupation:
Brother(s)/Sister(s): Name-Age-Occupation
ABOUT YOUR EDUCATION
School name:
School address:
Current grade:
Year you will graduate:
How many years have you studied English?
Do you speak any other languages besides your native language and English? Which ones?
Academic subjects you are most interested in?
Please describe the activities (extracurricular, community, hobbies) in which you have
participated, how long you have been involved with each, any awards or honors. Highlight any
experiences with diversity and disability groups.
Future studies and/or possible occupations you’ve considered?
UNCLASSIFIED
ESSAY QUESTIONS
Please respond to the following short essay questions in no more than 250 words each.
Do you think your country’s membership in ASEAN affects your daily life? How do you
think ASEAN can help your country address a challenge (such as climate change,
creating new jobs, or health issues) in the 21st century?
In what ways are you an effective leader? What leadership skills would you like to
improve?
Why do you want to join this program? How will your participation in this program
benefit your community?
MORE ABOUT YOU
Do you have a valid passport? If yes, move to the next questions.
Issuing Country:
Passport Number:
Expiration Date (MM/DD/YYYY):
Have you ever lived and/or studied in the United States or in another country?
If yes: Where, when, why?
APPLICANT SIGNATURE
All information in this application is accurate and true
Signature_________________________________________ Date _________
Parent/Guardian signature(s):
I permit my child to apply for and, if selected, to participate in this program.
Signature_________________________________________ Date _________
Signature_________________________________________ Date _________
UNCLASSIFIED
SOUTHEAST ASIA YOUTH LEADERSHIP PROGRAM
Reference
For the Applicant: Below, fill in your name and give this form to a teacher or other adult
outside your family who knows you well. The form does need to be in English. Ask the reference
to fill out the form and submit with your application form.
Applicant Name: ____________________________________________________________
For the Reference: The student named above is applying to take part in the Southeast Asia
Youth Leadership Program, a three-week exchange program in the United States for students and
teachers. 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.
Do you think the applicant would adapt well to unfamiliar environments and new situations?
Why or why not?
Name (printed):
Signature_________________________________________ Date _________
UNCLASSIFIED
