CENTRAL AMERICA YOUTH
AMBASSADORS PROGRAM - 2017 CYCLE
U.S. YOUTH APPLICATION
Background
Georgetown University’s Center for Intercultural Education and Development (CIED), the Bureau of Educational
and Cultural Affairs of the State Department and the U.S. Embassies in Central America are pleased to
announce the launch of candidate recruitment for the 2017 Central America Youth Ambassadors (CAYA)
program.
The CAYA program provides youth and adult mentors from the United States, specifically from Huntsville,
Alabama; Moscow, Idaho; Marquette, Michigan; Jacksonville, Florida; and Washington, DC, the opportunity for
a three week international exchange in Nicaragua and the Dominican Republic. During this youth diplomacy
experience participants will travel to the Dominican Republic and Nicaragua where they will have interactive
workshops, community service activities, field trips and cultural outings with local youth and community
leaders. These study tours will expand their knowledge of the culture, society and education in Central America
and the Caribbean. The CAYA program will be conducted in English and participants are encouraged to practice
their Spanish, improving their language skills. The Youth Ambassadors program not only provides participants
with new knowledge and unmatched experiences, it also develops new leadership skills and strengthens
commitment to civic engagement, social entrepreneurship and environmental initiatives.
Candidate Profile
 15 to 18 years old
 Citizenship: United States
 Still has one more year of high school after
the completion of the Program
 Public high school student and/or
participation in a community-based project
 Economically disadvantaged background
 No close relative who has previously
participated in the CAYA program
 Demonstrated leadership skills and
entrepreneurial and environmental interest
 Personal characteristics such as maturity,
integrity, social skills, open-mindedness
and motivation
 Intermediate level of Spanish
Participants for the 2017 program will be chosen through a selection process coordinated by GU/CIED, the
Education and Cultural Affairs Bureau of the Department of State and local partner institutions.
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2017 YOUTH APPLICATION FORM
INSTRUCTIONS
Please carefully read this application form before filling it out. You must answer all the questions and attach all
the required documentation for your application to be considered. If some questions do not apply please write
N/A (not applicable). Complete and send application to:
Anna Marie Siegel
Florida State College at Jacksonville
[email protected]
Phone: (904)632-3248
DOCUMENTS REQUIRED
Please send the following documentation with your application*:
1.
2.
3.
4.
5.
6.
Copy of birth certificate
Two passport pictures
Copy of valid passport if possible (it is not mandatory to have a passport to apply to the program)
Copy of parents/legal guardians’ valid ID
Application form
Annexes (See annexes attached at the end of this application form):





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Annex # 1: Letter of Recommendation # 1
Annex # 2: Letter of Recommendation # 2
Annex # 3: Parental Authorization
Annex # 4: Liability Waiver and Authorization for Medical Treatment
Annex # 5: Medical Certificate Addendum
Annex # 6: Code of Commitment
Annex # 7: Questionnaire for host family stay
* Note: Please do not send the original documents. All documentation sent to Georgetown University will not
be returned.
IMPORTANT DATES (Check with the CAYA local coordinator for specific dates)





January 20th to February 28th, 2017
February 28th to March 10th, 2017
March 30th, 2017
June of 2017 (Specific date TBD)
July 9- August 2, 2017
Candidate recruitment period
Candidates interview and pre-selection process
Final selection by Georgetown U. and the Department of State
Pre-departure orientation
Three weeks of CAYA Program in the Dominican
Republic and Nicaragua
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Please attach two (2)
pictures
__________________________
First Name
___________________
Middle Name
___________________________
Last Name
__________________________
Date of Birth
(month/day/year)
___________________
Age
__________________________
State
Tell us a little bit about yourself and your family:
Tell us a little bit about your hobbies and interests:
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I.
PERSONAL INFORMATION
Name:
Last Name
First Name
Street:
Street Name and Number
City and State
Contact Information:
Phone Number (complete)
E-mail
II.
BIOGRAPHIC DATA
1.
Place of Birth: _________________________
City
2.
Date of Birth: _________________________
(month/day/year)
3.
Gender:
Female
Male
4.
Marital Status:
Married
Single
5.
Ethnic Background:
________________
Country
Caucasian
American Indian
African American
Asian or Pacific Islander
Hispanic
Eskimo or Aleut
Other, please specify__________________________________________
6.
Do you have any physical disability?
No
Yes
Explain:_____________________________
7.
Do you have any medical condition?
No
Yes
Explain:_____________________________
III. EDUCATIONAL BACKGROUND
1.
Schools Attended:
Name of Institution
Major Field
Starting
year
Ending
year
Degree Received
Primary School
High School
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2.
Indicate any awards or academic honors received:
_________________________________________________________________________________
3.
Have you ever attended a private school?
Yes
No
4.
Have you ever received a scholarship or financial aid?
Yes
No
5.
If your answer to question #4 is yes, please give the following information:

How much money did you receive? (Amount): $ ________________________________________

Who gave it to you? (Institution): ____________________________________________________

For how long did you receive this financial aid? (Period): _________________________________
6.
Are you currently enrolled in school?
7.
If your answer to question # 6 is yes, answer the following questions:
a. Types of classes:
Day
Yes
No
Night
b. Current GPA: ______________________
c. Name of the institution you are attending: ______________________________________________
d. Indicate your major area(s) of study: ___________________________________________________
e. When do you plan on graduating:
8.
__________
Month and Year
Do you speak any languages other than English? Yes
No
If yes, please complete the section below. Use the following letters to rate your ability:
E = Excellent G = Good F = Fair
Language
Speaking
Level
Reading
Level
Writing
Level
Learned Where
Years of Study
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IV. WORK EXPERIENCE
1.
Have you ever worked? (Including both formal and informal jobs) Yes
No
2.
If your answer to question #1 is yes, please give the following information based on your most recent jobs:
Job 1
1.
Name of company where you work/worked:
2.
What is/was your position?
3.
Provide a brief description of your responsibilities:
_________________________________________________________________________________
4.
What are/were your beginning and ending dates of employment?
__________________
Beginning date
__________________
Ending Date
5.
What is/was your monthly salary? ___________________
6.
How many hours you work/worked per week? _______________
Job 2
1.
Name of company where you work/worked:
2.
What is/was your position?
3.
Provide a brief description of your responsibilities:
_________________________________________________________________________________
4.
What are/were your beginning and ending dates of employment?
__________________
Beginning date
__________________
Ending Date
5.
What is/was your monthly salary? ___________________
6.
How many hours you work/worked per week? _______________
V.
1.
FAMILY INFORMATION
With whom do you live? Mark all the appropriate responses
Father
Mother
Guardian
Siblings
Other: ____________
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2. Name of Mother/Legal Guardian: ___________________________ _________________________
Last Name
First Name
Name of Father/Legal Guardian: ___________________________ _________________________
Last Name
First Name
3.
Do you have any family member that has participated in the CAYA program?
4.
Have you ever traveled out of the country?
5.
If your answer to question #4 is yes, please mark the reason why you travelled?
Yes
Yes
No
No
Tourism
Other: ________________________________________________________
6.
Have you ever traveled to Central America?
Yes
No
7.
If your answer to question #6 is yes, please mark the reason why you travelled?
Tourism
Other: ________________________________________________________
8.
Do you have a passport?
Yes
No
9.
If your answer to question #8 is yes, please give the following information:
Passport Number: ______________________
Place of Issue: _____________________
Issuing Country: ________________________
Date of expiration: _________________
(month/day/year)
10. Emergency Contact Information. It is very important that we have an emergency contact other than your
permanent address.
Name:
Last Name
First Name
Relationship to applicant: _________________________________________________________________
Street:
______
Street Name and Number
Contact Information:
City and State
______
Phone Number
11.
E-mail
Please indicate the person or organization that gave you this application form:
_______________________________________________________________________________
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Any false information submitted will cause the immediate disqualification of the candidate
VI. QUESTIONS FOR THE APPLICANT
Please provide answers to the following questions. Answers should be as specific as possible.
1. Suitability of the applicant: Why do you feel you are an ideal candidate for this exchange experience?
Please explain.
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Any false information submitted will cause the immediate disqualification of the candidate
2.
Community involvement: Write about an environmental problem currently affecting your community. If it
were within your abilities, how would you solve this problem?
____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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This material is free. It’s sale is illegal.
Any false information submitted will cause the immediate disqualification of the candidate
3.
Leadership: Please list your extracurricular activities and/or your involvement in community groups in the
spaces provided below. Be specific about your responsibilities and leadership roles.
Activities
Position Held
Period
(Dates)
Location
Have you been a
member of an
extracurricular club
or association at
school?
If yes, explain:
Have you
participated in
entrepreneurial
and/or
environmental
initiatives? If yes,
explain:
Have you
participated in any
community-based
activities? If yes,
explain:
I certify that the information contained in this application, including all attachments and supporting
credentials, is complete and correct.
_____________________________________
Applicant’s signature
___________________________________
Date
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Any false information submitted will cause the immediate disqualification of the candidate
ANNEX #1 Central America Youth Ambassador Program
Letter of Recommendation for Youth # 1
INSTRUCTIONS:
This form should be filled out by someone who has worked directly with the applicant (teacher, supervisor,
community leader, etc.). Recommendations from friends or relatives will not be accepted.
Applicant’s Full Name
Name of Recommender
___
Name
____________________________
Title
Institution
Your opinion about the applicant will be a great help in the selection process. It is very important that your
comments and responses are sincere and detailed. After completing this form, please return it to the applicant
in a sealed and signed envelope. Thank you for your cooperation.
1. How long have you known the applicant and in what capacity?
2. In the following table, please indicate the intellectual capacity and personality of the applicant compared to
his/her peers.
Qualities
Unsatisfactory
Below
Average
Average
Very Good
Ability to express
his/herself
Ability to take on
responsibilities
Motivation and
entrepreneurial spirit
Maturity and ability to
work with others
Youth leadership
qualities/potential
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Excellent
3. Describe situations in which the applicant has shown leadership skills and entrepreneurial or environmental
spirit.
_______
_______
4. How does the applicant interact with his/her peers and teachers? Are there some aspects of the applicant’s
behavior that could be improved?
_______
_______
5. Give an example of how the applicant has successfully adapted to a new or different situation.
_______
_______
6. What are some of the applicant's outstanding personal characteristics? Please mention below any additional
information that you consider important for evaluating the applicant.
_______
_______
Signature of Recommender
Name
Date
Position
Name, Address, and Telephone Number of the Office or Institution:
_______
_______
This material is free. It’s sale is illegal.
Any false information submitted will cause the immediate disqualification of the candidate
ANNEX #2 Central America Youth Ambassador Program
Letter of Recommendation for Youth # 2
INSTRUCTIONS:
This form should be filled out by someone who has worked directly with the applicant (teacher, supervisor,
community leader, etc.). Recommendations from friends or relatives will not be accepted.
Applicant’s Full Name
Name of Recommender
___
Name
____________________________
Title
Institution
Your opinion about the applicant will be a great help in the selection process. It is very important that your
comments and responses are sincere and detailed. After completing this form, please return it to the applicant
in a sealed and signed envelope. Thank you for your cooperation.
1. How long have you known the applicant and in what capacity?
2. In the following table, please indicate the intellectual capacity and personality of the applicant compared to
his/her peers.
Qualities
Unsatisfactory
Below
Average
Average
Very Good
Ability to express
his/herself
Ability to take on
responsibilities
Motivation and
entrepreneurial spirit
Maturity and ability to
work with others
Youth leadership
qualities/potential
This material is free. It’s sale is illegal.
Any false information submitted will cause the immediate disqualification of the candidate
Excellent
3. Describe situations in which the applicant has shown leadership skills and entrepreneurial or environmental
spirit.
_______
_______
4. How does the applicant interact with his/her peers and teachers? Are there some aspects of the applicant’s
behavior that could be improved?
_______
_______
5. Give an example of how the applicant has successfully adapted to a new or different situation.
_______
_______
6. What are some of the applicant's outstanding personal characteristics? Please mention below any additional
information that you consider important for evaluating the applicant.
_______
_______
Signature of Recommender
Name
Date
Position
Name, Address, and Telephone Number of the Office or Institution:
_______
_______
This material is free. It’s sale is illegal.
Any false information submitted will cause the immediate disqualification of the candidate
ANNEX #3 Central America Youth Ambassador Program
Parental Authorization
I/We hereby grant permission for my/our son/daughter ________________________________, to participate
in the 2017 Central Youth Ambassadors Program that will be held in Nicaragua and the Dominican Republic.
___________________________
Name of Mother/Legal Guardian
______________________________
Mother/Legal Guardian’s Signature
_____________
Date
___________________________
Name of Father/Legal Guardian
______________________________
Father/Legal Guardian’s Signature
_____________
Date
Note:
•In the case where one of the parents is deceased, please provide a copy of the death certificate.
•If parents are separated or divorced, please provide information on the parent not living in the student's
household.
Contact Information:
Street:
Street Name and Number
City and State
Contact Information:
Phone Number (complete)
E-mail
This material is free. It’s sale is illegal.
Any false information submitted will cause the immediate disqualification of the candidate
ANNEX #4 Central America Youth Ambassador Program
Liability Waiver and Authorization for Medical Treatment
This form applies to all candidates who intend to participate in the Central America Youth Ambassadors
Program (CAYA). This form must be signed by the parents or guardians if the student is under 21 years of age.
This document establishes the following:






Authorization to participate in the CAYA Program, which includes travel to Nicaragua and the Dominican Republic and
all program activities during the three week exchange.
Authorization permitting the Program Director, or his or her designee, to obtain medical treatment in the event that
such a need should arise while the student is abroad. In the event of sickness or personal injury, I hereby authorize the
Program Director, or his or her designee, to secure whatever treatment is deemed necessary, including the admission
to a hospital, the administration of anesthetics, the transfusion of blood, and surgery. All necessary precautions will
be taken to avoid accidents and mental and/or physical health problems, however, program officials must be in a
position to act should such need arise.
Authorization permitting any medical or health care provider to release any and all medical histories and
documentation on the student to Georgetown University and/or the partner CAYA educational institution in
Nicaragua and the Dominican Republic.
Acknowledgement that while the participant is in Nicaragua and the Dominican Republic, Georgetown CIED has
enrolled him/her in an adequate medical insurance program, specifically the Accident and Sickness Program for
Exchanges (ASPE) sponsored by the U.S. Department of State.
Acknowledgement that student is travelling to a country on the Centers for Disease Control (CDC) list for the Zika
disease (please ensure that you review the CDC website for Zika facts and recommended preventative measures).
This Authorization releases the U.S. government, Georgetown University and all Program representatives, employees,
volunteers, and officers from any and all claims or causes of action for loss of property, mental and/or physical illness,
personal injury or death sustained by the participant arising out of any travel or activity conducted by, in support of,
or under the auspices of this Georgetown University Program.
Your signature constitutes your acceptance of these terms and conditions:
Participant Name: ________________________________
State: ______________________
Participant Signature: _____________________________
Date: ________________________
……………………………………………………………………………………………………………………………………………………………………………
For participants younger than 21 years old:
Your signature constitutes your review and acceptance of these terms and conditions:
I hereby give permission for
__________________________, (name of participant) to
participate in the CAYA Program to be held in Nicaragua and the Dominican Republic.
I understand that Georgetown University has enrolled
_________________, (name of
participant) in a medical insurance program sponsored by the U.S. Department of State, the Accident and
Sickness Program for Exchanges (ASPE), which will provide coverage of reasonable and eligible health care
costs beginning on the day of departure continuing throughout the term of the CAYA exchange in Central
America.
_____________________________
Name of Father or Legal Guardian
________________________________
Signature of Father of Legal Guardian
_____________
Date
_____________________________
Name of Mother or Legal Guardian
________________________________
Signature of Mother of Legal Guardian
_____________
Date
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Any false information submitted will cause the immediate disqualification of the candidate
ANNEX #5 Central America Youth Ambassador Program
Medical Certificate Addendum
1. Participant’s Name: _______________________________________________________________
2. Date of Birth:__________________________
Place of birth:_________________________
3. Childhood diseases: _______________________________________________________________
4. Surgeries: _______________________________________________________________________
5. Allergies or dietary restrictions:______________________________________________________
6. Allergies to medicine (like penicillin): _________________________________________________
7. Infectious diseases: _______________________________________________________________
8. If participant has epilepsy, please indicate:
-
Type of seizures:
-
Frequency of seizures? _________________
-
If taking any epilepsy medications please detailed the name and dosage: ____________
Gran Mal
Petit Mal
________________________________________________________________________
9. Is the participant diabetic?
No
Yes
Medications? __________________________
10. Is the participant asthmatic?
No
Yes
Medications? __________________________
11. Vaccines: Please attach your vaccination official records all documentation for past vaccinations
Type of Vaccine
Vaccination date
(month/day/year)
Diphtheria
Tetanus
Rubella
Measles
Chicken Pox
Poliomyelitis
Mumps
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12. Does the participant have any history or present evidence of nervous, emotional, or mental problems?
Yes
No
If yes, please explain:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
13. Will the student be taking any prescribed medication during the exchange trip?
Yes
No
If yes, what medication?
Generic name, dosage, and reasons of medication:
______________________________________________________________________________
______________________________________________________________________________
Note: Some medications are restricted in certain countries; please have the student check at YFU
USA (http://yfuusa.org/). Students should carry a prescription for their medication when they travel;
the generic name of the drug should be noted on the prescription.
14. Is the participant willing to eat?*
Fish/Shellfish
Yes
No
Poultry
Yes
No
Pork
Yes
No
Beef
Yes
No
Dairy
Yes
No
Everything
Yes
No
* If vegetarian, keep in mind that the program will try to offer you a special menu but in some
circumstances the options may be limited.
This material is free. It’s sale is illegal.
Any false information submitted will cause the immediate disqualification of the candidate
ANNEX #6 Central America Youth Ambassador Program
Code of Commitment
By accepting to be a participant in the Youth Ambassadors program I acknowledge that I understand and
commit to the program goals and expectations and that I acknowledge that I am responsible for my actions and
behavior during the three-week program in Nicaragua and the Dominican Republic. I understand that
Georgetown University has rules and behavior to follow that I will obey, together with the laws of Nicaragua
and the Dominican Republic.
The following principles reflect the conduct expected of each participant in the Youth Ambassadors program:
1. Attend all activities of the Youth Ambassadors program, comply with all the tasks assigned in the
program, and participate actively.
2. Accept local customs and share my own culture with other people in the communities visited,
especially during the host family stay and with other young people from the program.
3. Maintain proper personal hygiene.
4. Respect the rights and differences of all who comprise the group, taking into account that both women
and men and all the people from other races and religions must be treated equally with fairness and
respect.
5. Be responsible for safeguarding your own money and valuables to reduce the risk of loss or theft. The
Program will not be responsible for loss of money or valuables.
6. Moderately use electronic equipment, such as computers, Internet, tablets or phones. When staying
with host families, always request permission to use the equipment. Computer and telephone use
should be limited so that you can dedicate time with your host family.
7. Do not violate U.S. federal or state laws, which prohibit:
a.
b.
c.
d.
e.
f.
Purchase and/or consumption of alcoholic beverages if you are under 21 years of age
Purchase, sale and/or use of drugs
Rape or sexual assault
Sexual harassment, threats or intimidation (verbal, written, physical) of any kind
Shoplifting
Carrying weapons (guns, knives, etc.), insult or assault
Disciplinary Policy
Any failure to comply with the laws of the United States, the participating overseas countries and/or rules of
the program will result in an official warning and may be the cause for which the participant is dismissed from
the program. People who commit a violation of local, state and federal regulations shall be subject to a legal
process under the judicial system in Nicaragua and the Dominican Republic. A participant may be prosecuted
and sentenced to a term of imprisonment if found guilty.
_________________________________
Participant’s Name
________________________________
Participant’s signature
___________
Date
This material is free. It’s sale is illegal.
Any false information submitted will cause the immediate disqualification of the candidate
ANNEX #7 Central America Youth Ambassador Program
Questionnaire for host family stay
Name ________________________________________ Age ______
State ___________________
1. Do you speak Spanish?
No____ Yes____ How well?________________________________
2. Do you have siblings?
No ____ Yes____ How many?________________________________
3. Do you like pets?
No ____ Yes____ Which ones?_______________________________
4. Do you have allergies?
No ____ Yes____ To what?__________________________________
5. What type of food do you like? ________________________________________________________
____________________________________________________________________________________
6. Do you have any dietary restrictions? ________________________________________________
____________________________________________________________________________________
7. What is your t-shirt size? XS
S
M
L
XL
XXL
8. Please list what time you usually do the following activities:
● Wake up
_______
● Breakfast
________
● Eat dinner
_______
● Go to bed
________
9. What would you like to talk/learn/experience with your host family?
____________________________________________________________________________________
____________________________________________________________________________________
10. What do you think will be your biggest challenge during your stay with the host family?
____________________________________________________________________________________
____________________________________________________________________________________
11. What kind of responsibilities/tasks would you like to have during your stay with the host family?
____________________________________________________________________________________
____________________________________________________________________________________
12. How would you like to resolve conflicts that may arise while you stay with your host family?
____________________________________________________________________________________
____________________________________________________________________________________
This material is free. It’s sale is illegal.
Any false information submitted will cause the immediate disqualification of the candidate