US-CRMYouthExchange

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					                                                               Applicant name: First name SURNAME


                           U.S. CIVIL RIGHTS MOVEMENTS YOUTH
                           EXCHANGE PROGRAM
                           FY2014 NOMINATION FORM
PLEASE EMAIL YOUR COMPLETED APPLICATION TO:
culturelondon@state.gov with the subject “Leadership- Exchange Program”

DEADLINE: MAY 1, 2014

SECTION 1 – To be completed by the Candidate

CANDIDATE:                  Surname, First name Middle name(s)
Names as in Passport

NATIONALITY: Current/previous &/or dual nationality SEX: Select sex               AGE: e.g. 17

CANDIDATE’S SCHOOL
Name and full address of School

SHORT ESSAY QUESTIONS

1. What interests you about the U.S. Civil Rights Movement?
Please enter your response here. Max 250 words.

2. Do you take an interest in UK politics/social issues? Have you ever been active as a
campaigner (at school, in your local community, on a national level etc)? If so, describe
what you were involved in and why?
Please enter your response here. Max 250 words.

3. Which public figure do you most admire and why?
Please enter your response here. Max 250 words.

4. Describe why you are a good candidate for an exchange program.
Please enter your response here. Max 250 words.

CANDIDATE’S CONTACT DETAILS
Student Home Address:   Number, Street, City, County, Postcode
Student Mobile:   Mobile number Student’s Email:        Email address

Parent/Guardian Name: Name            Parent/Guardian Address: Number, Street,
                                      City, County, Postcode
Parent/Guardian Mobile: Mobile        Parent/Guardian Email: Email address
number

DATE OF BIRTH               Month Day, Year e.g. November 12, 1991
                                                     U.S. Civil Rights Movements Youth Exchange application
                                                                      Applicant name: First name SURNAME

PLACE OF BIRTH                  Give town/city and country

PREVIOUS U.S. TRAVEL
Include purpose of travel, approximate dates (arrival/departure) and places visited in that order -
please put most recent first

PREVIOUS TRAVEL (non-U.S.)
Include purpose of travel, approximate dates (arrival/departure) and places visited in that order -
please put most recent first

PASSPORT NUMBER                 Enter passport number
PLACE OF ISSUE                  Give city and country
DATE OF ISSUE                   Month Day, Year e.g. September 19, 2005
DATE OF EXPIRATION              Month Day, Year e.g. September 19, 2015

MEDICAL, PHYSICAL AND DIETARY CONSIDERATIONS?                                      Choose Yes/No
If applicable, list allergies or food restrictions (halal/vegetarian e.t.c.); or other issues such as fear
of flying; if not applicable, write “none”




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                                                  U.S. Civil Rights Movements Youth Exchange application
                                                                   Applicant name: First name SURNAME

SECTION 2 – To be completed by the Nominating Teacher

NOMINATING TEACHER:
Nominator’s name; Nominator’s Title; Tel number; Email address

STUDENT’S NAME: Enter name here.

SUPPORTING REFERENCE
Questions you may wish to address include, why do you support this student’s application; what
distinguishes this young person (in term of academic work, extra-curricular activities etc); is this
person receptive to new experiences? Please keep you reference to under 500 words.

Please write you reference here.




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