The Bureau of Educational and Cultural Affairs U.S. Department of State through Northern Illinois University (DeKalb, U.S.A.) in partnership with Filipino Institute for the Promotion of Integrity & Nobility (FILIPINO, Inc) Philippine Youth Leadership Program Batch 13 (2015-2016) Theme: Environmental Leadership in the Philippines: Developing Youth as Agents of Change and Ecological Activism A one-year project that covers workshops and learning activities, including a four-week campusbased study and exposure period in the U.S., focusing on responsible citizenship, community service leadership and action plan development and implementation. APPLICATION FORM: YOUTH PARTICIPANT Please print legibly and do not leave any item unanswered. Applications with incomplete entries or supporting documents and without parents or guardian s consent may be subject to disqualification. Completed forms and required documents should be placed in a sealed envelope and sent to Dr. Lourdes Tolod, School of Education, Xavier University, Cagayan de Oro City. Applicants should notify the PYLP Area Coordinator or Contact person as to the transmission details. Deadline for submission: November 25, 2015. Photo Passport Size Date taken PERSONAL INFORMATION: (To be eligible, you must be at least 15 years old and not more than 17 years old by April 2016.) First Name (CAPITALS please): Middle Name (CAPITALS please): Last Name (CAPITALS please): Sex: Male Female Age: Date of Birth: Birth Place: Religion: Ethnicity /Tribe: Home Address: Permanent Mobile#: Permanent Email Add: Grade Level/Year & Course: Grade Average: (For Junior High School, submit latest form 138 or 2 nd grading period records of school year 2015-2016; for First Year College: First Semester Grades SY 2015-2016). PYLP 13 Youth Application Form Page 1 of 5
Please write down any special skills that you have: PASSPORT INFORMATION: Do you currently hold a Philippine Passport? Yes No Date of Issue: Valid Until Place of Issue: PARENTS INFORMATION: Father s Name: Birthday: Age: Birthplace: Ethnicity: Religion: Occupation: Mother s Name: Birthday: Age: Birthplace: Ethnicity: Religion: Occupation: Parents Address (if not the same as above): Father s Permanent Mobile #: Mother s Permanent Mobile # SCHOOL/INSTITUTION INFORMATION: Name of school: Address: Name of school head: Permanent Mobile #: Email Add: PARTICIPATION IN SCHOOL- and COMMUNITY-BASED ACTIVITIES: Membership in school organizations and civic clubs at least as far back as two years to the present. Please attach authenticated photocopies of proof of membership by the organizer or school adviser and activity participation record. PYLP 13 Youth Application Form Page 2 of 5
Membership in other organizations or non-government organizations (NGOs) at least as far back as two years to the present. Please attach authenticated photocopies of proof of membership by the organizer or school adviser and activity participation record.) Titles and dates of other workshops participated in related to peace-building, leadership and environment at least as far back as two years till the present. Please attach authenticated photocopies of certificates of attendance or participation by the organizer or school adviser: OTHER INFORMATION: Do you have any immediate relative(s) or cousin(s) within the first degree of consanguinity who are recipients of a study grant or have participated in a U.S. Department of State program? If NO, proceed to REFERENCES; if YES, please answer the following: Name: Relationship: Name & Year of Program: REFERENCES: (Kindly provide below two (2) names of disinterested persons who know you well as character references.) Name (1): Relationship: Position: School/Organization: Permanent Mobile # Permanent Email Add: Name (2): Relationship: Position: School/Organization: Permanent Mobile # Permanent Email Add: OTHER REQUIREMENTS: 1. Two essays: (a) Please write something about yourself in a short essay of not more than 1,000 words. (b) On another sheet, please share with us your perceptions on critical needs and issues confronting your community and the related possible projects that would help improve and develop your local community. These two essays should be attached to the application form. PYLP 13 Youth Application Form Page 3 of 5
2. Documents(All documents should be authenticated by concerned organization/institution) a) Scanned or photocopy of birth certificate issued by the National Statistics Office/NSO b) Scanned or photocopy of high school report card or first semester grades in college c) Scanned or photocopy of Certifications of Good Moral Character d) Scanned or photocopy of Certificates of Membership in organizations e) Scanned or photocopy of Certificates of Participation in seminars/workshops f) Scanned and original copy of endorsement of your application by your school g) Scanned or photocopy of parents marriage certificate or CENOMAR (if applicable) h) Scanned or photocopy of parents birth certificates i) Completed Application Form with signed Certification and Consent (at the bottom of this form). j) Signed and notarized Affidavit of Consent and Certificate of Undertaking by parents or guardian (draft attached). CERTIFICATION AND CONSENT I hereby certify that I have read and understood all sections of this form and that all facts and information placed herein are true and correct to the best of my knowledge. I further declare that any information given by me that may be untrue will be grounds for disqualification to the program. Further, I subscribe and agree that the PYLP Selection Committee has the sole prerogative to select and nominate the delegates, and its decision is final and executory. If selected as a participant, I commit to participate actively in all the activities of the program. (Signature over printed name of applicant) Date: With our Conformity: (Father s/guardian s Signature over Printed Name) Date: (Mother s/guardian s Signature over Printed Name) Date: When submitting applications, please ensure completeness of information and requirements specified. Applications may be received by any of the following coordinators and/or contact persons: South Cotabato Al Quillope Email: earthworm_afq@yahoo.com / Phone #: (0921) 560 0702 Notre Dame of Marbel University, Koronadal City, South Cotabato General Santos City and Sarangani Province Allan Remedios Email:onjie123@gmail.com / Phone # (0998) 860 9030 Holy Trinity College, Gen. Santos City PYLP 13 Youth Application Form Page 4 of 5
Cotabato City and Maguindanao Province Dr Alfred Born Taboada Email: alfredborntab@gmail.com / Phone # (0918) 579 5835 Address: Dean, STI College, Dorotheo St., Cotabato City Misamis Oriental, Lanao del Norte, Lanao del Sur, Bukidnon, Caraga Region Mona Lisa Pangan Email: monliz_75@yahoo.com / Phone #: (0906) 441 1509 Campus Ministries Office, Xavier University, Cagayan de Oro City 9000 Jana Jean Dacobor Email: janjayn@yahoo.com/ Phone #: (0917) 716 9023 Door 2 Silatan Apt. Zone 3, Bagong Silang Highway 9200Iligan City Zamboanga City, Zamboanga del Norte, Zamboanga Sibugay, Sulu, Tawi-Tawi and Basilan Cecille Ancheta La Plana Email: cecillelaplana@gmail.com / Phone #: (0927) 57819142 Purok Orchids, Tirso Babiera Dr., African Daisy St. Poblacion, Ipil, Zamboanga Sibugay 7001 Zamboanga del Sur Mohamad Ali Esmael Ramber Email: moal_ramber@yahoo.com/ Phone # 0916-7341661 Purok Sunshine, Alano St., Santiago, Pagadian City Coordinating Center: Dr Lourdes Tolod Email: ltolod@yahoo.com / Phone #: (0917) 716 9292 School of Education, Xavier University Cagayan de Oro City 9000 Notes: 1. Shortlisted Applicants will be directly notified as to date and location of the final interview. 2. Applicants who have family members (father, mother, sister or brother) and cousins within the first degree of consanguinity who have participated in any US Department of State sponsored grants may be subject to disqualification. PYLP 13 Youth Application Form Page 5 of 5