APPENDIX 1: SAMPLE APPLICATION FORMS
“Sports and Disabilities – Opportunities and Awareness”
A WorldChicago Exchange Program for Brazil and the United States
Sponsored by the US Department of State’s SportsUnited Office
July 17 – 27, 2013
US Student Application
APPLICATION DEADLINE – May 24, 2013
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Program Introduction and Application Instructions
WorldChicago’s “Sports and Disabilities – Opportunities and Awareness” Exchange Program in 2013 will bring 14 students and 6 adults from Brazil to Chicago for a 10 day program from July 17 to 27. The program will also include 6 students from the Chicago Metropolitan Area.
This US Department of State sponsored program will focus on physical fitness education and athletic training for the program participants, and workshops on leadership, advocacy, and the role of volunteerism in increasing opportunities for people with disabilities in Brazil and the United States.
The program will provide an opportunity for US student participants to develop their leadership and advocacy skills, participate in sports activities, enhance their cross cultural communication skills, and learn about Brazilian culture. Through participation in the program, US and Brazilian students will be charged with developing a collaborative project aimed at making a positive impact on sports opportunities for youth with disabilities in the United States and Brazil.
Student applicants for the program should be between the ages of 16-19 years old and demonstrate an interest in community service and sports. All program costs (downtown lodging at Roosevelt University, meals, transportation during program, cultural activities) are covered through the program. Adult leaders from the Chicago Metropolitan area and Brazil will serve as chaperones throughout the 10 day program (both days and nights).
Program Timeline & Outline
|Sunday |Monday |Tuesday |Wednesday |Thursday |Friday |Saturday |
| | | |July 17 |July 18 |July 19 |July 20 |
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| | | |International Arrival |AM – initial team action |9 am – 1 pm |Civic Education |
| | | | |planning session |Judd Goldman Adaptive |programming with |
| | | |University Center | |Sailing/RIC sports at |Volunteer Project |
| | | |Check-in |PM – Advocacy training |Harbor | |
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|July 21 |July 22 |July 23 |July 24 |July 25 |July 26 |July 27 |
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|Cultural Day |Sports Physical |Sports Physical |Sports Physical |Civic Education/Advocacy |Program Evaluation |International |
| |Fitness Education |Education Training |Education Training |Wrap-up sessions |Session |Departures for |
| | | | | | |Brazilian students |
| | | | | | |(Chicago students |
|2 pm- Partners | | | | | |depart) |
|of the Americas | | | | | | |
|Summer Picnic | | | | | | |
| |Evening – Chicago |Welcome picnic w/travel| |Free Night | | |
| |White Sox Game |delegation & | | |Evening – Program | |
| | |paralmpians | | |Closing Dinner | |
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Application Submission Instructions
Applications should be submitted by email, mail or fax.
Applications submitted by email should go to Jbaum@. By fax, (312)254-1805 or by mail;
WorldChicago
72 E. Randolph Street – 2nd Floor
Chicago, IL 60601
Application Questions
Application questions should be directed to John Baum at WorldChicago:
John Baum
Associate Director – Programs
WorldChicago
(312)254-1800 ext. 100; jbaum@
STUDENT BACKGROUND INFORMATION
|Student Information |
|NAME | | | |
|(As it appears on gov’t ID) |Last |First |Middle |
|First name as it would appear on nametag | |
|PERMANENT STREET ADDRESS | |
|CITY, STATE, ZIP CODE | |
|EMAIL | |
|PERMANENT PHONE | |
|MOBILE PHONE | |
|DATE OF BIRTH (mm/dd/yyyy) | |
|PLACE OF BIRTH | |
|COUNTRY OF CITIZENSHIP | |
|GENDER | Male | Female |
|How did you first hear about the exchange program? (Please be as specific as possible.) |
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|Do you have a passport? If so, please include a photo copy of the bio data page (the page with your picture and passport number on it) |
|along with your completed application. (Yes) (No) |
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|School Information |
SCHOOL CURRENTLY ATTENDING
|SCHOOL ADDRESS | |
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|SCHOOL GRADE | |
Have you ever lived and/or studied outside of the United States? YES NO
If yes, please provide a brief description including dates and location.
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|Languages |
What is your native language?
|List other languages you may have. |
|Language | |Number of years studied | |
|Language | |Number of years studied | |
|Language | |Number of years studied | |
PARENT/ GUARDIAN INFORMATION
Note: Please attach the signed Parent/Guardian approval form. Make sure to fill out the form at the end of this application.
Parent/Guardian 1
|NAME/RELATION TO YOU | |
|ADDRESS | |
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|TELEPHONE & EMAIL | |
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Parent/Guardian 2
|NAME/RELATION TO YOU | |
|ADDRESS | |
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|TELEPHONE & EMAIL | |
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DISABILITY INFORMATION:
Please describe the nature of your disability or list any information here that would be helpful in program planning
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Assistive devices you will be traveling with (for planning transportation and sports program needs.)
Comments/Details
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APPLICATION QUESTIONS:
6 Are you currently engaged in sports? Please explain below what sports you are involved in.
2. Are you involved in community service in your home community? Please provide examples of community service projects or other extracurricular activities you are currently involved in the boxes below.
|Activity/ Description |Number of years |Number of hours per |
| |participated in |week |
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3. Please provide an example of a time when you took a leadership role on a sports team, an extracurricular activity, or a community service project.
4. What knowledge and skills do you hope to gain as a result of participating in this exchange program?
5. What do you hope to learn from your Brazilian youth partners in this program? What would you like to share with them?
6. What types of activities do you think youth can engage in to increase opportunities for people with disabilities?
Parent/Guardian and participant Agreement
“Sports and Disabilities – Opportunities and Awareness”
A WorldChicago Exchange Program for Brazil and the United States
Sponsored by the US Department of State’s SportsUnited Office
July 17 – 27, 2013
All applicants must submit a signed parent or legal guardian form with their application giving permission to participate in the Brazil – US Sports and Disabilities Leadership Program Without a signed form from a parent or legal guardian, the application will not be considered.
I agree that all of the information in this application is true and I agree that if chosen to participate, the applicant will participate in ALL program activities in the United States.
Applicant Signature Date
Parent/Guardian Printed Name Date
Parent/Guardian Signature Date
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