Youth Ambassador Application | Mesa Sister Cities

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Student Information

Date*

Name*

First Middle Last

Nickname

Permanent Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Cell Phone*

Email*

Sex*

Height*

Birth Date*

Tell us more about you...

School*

Age next June 1st*

Please enter a number from 15 to 18.

Grade level next year*

Freshman
Sophomore
Junior

Do you speak a foreign language?*

Yes
No

Foreign Languages Spoke*

Click the + to add additional languages.

Language	How Long

Country of Birth*

Country of Citizenship*

List School/Church/Community activities in which you participate.*

Click the + to add additional activities.

Tell us about your hobbies.*

Work Experience*

What are your plans for the future? (Education and Career)*

What summer plans do you have?*

Father's Information

Father's Full Name*

First Middle Last

Father Living or Deceased*

Living
Deceased

Father's Age*

Country of Birth*

Home Phone

Cell Phone

Work Phone

Occupation*

Work Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mother's Information

Mother's Full Name*

First Middle Last

Mother Living or Deceased*

Living
Deceased

Mother's Age*

Country of Birth*

Country of Citizenship*

Home Phone

Cell Phone

Work Phone

Occupation*

Work Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Family and Travel

Do you have any siblings?*

Yes
No

Brother(s)

Name	Age

Sister(s)

Name	Age

Have you traveled abroad?*

Yes
No

Trips*

Location	Approximate Dates	How Long

Do you have any relatives living abroad?*

Yes
No

Relatives

Who	Where

Have any of your siblings participated in foreign exhange?*

Yes
No

Which siblings*

Name	Where	Appr. Dates

Has your family ever hosted a foreign exchange student?*

Yes
No

Details*

Country	Dates of stay

Have you or your family done volunteer work for the Mesa Sister Cities Program?*

Yes
No

Please describe volunteer work.

What is the state of your health?

Are you taking any medications*

Yes
No

Do you have food or pet allergies?

Yes
No

Please describe allergies

Are you afraid to travel by airplane?

Yes
No

Do you experience motion sickness?

Yes
No

Essay

Student Personal Statement

If you would prefer to attach your statement as a separate document, you can use the "optional attachments" field below.

Parent Input

Mother’s Statement and Description of Student

If you would prefer to attach your statement as a separate document, you can use the "optional attachments" field below.

Father’s Statement and Description of Student

If you would prefer to attach your statement as a separate document, you can use the "optional attachments" field below.

Student Headshot*

Max. file size: 50 MB.

Optional Attachments

If you prefer to attach document files or have any supplemental information to share, please upload them here.

Drop files here or

Max. file size: 50 MB.

Consent

I understand that a passport will be needed for travel and if selected, I will apply for and show proof of passport by the deadline set by Mesa Sister Cities Coordinator.

Signature of Applicant*

I understand that if chosen, I must abide by all rules of responsible conduct expected of me while living with a host family. I further understand that I am expected to live or attend school in Mesa during my senior year in high school.,

Signature of Parent or Guardian*

My son/daughter has my permission to apply for and participate in the Mesa Sister Cities Youth Ambassador Exchange Program with Burnaby Canada, Caraz Peru, Guaymas Mexico, Kaiping China and Upper Hutt New Zealand. I (we) have read and understand the attached sheet explaining the program and our responsibilities. As the applicant's parent and/or guardian, and in the event my son/daughter is selected for the student exchange program, I hereby agree to authorize the host family in the above mentioned cities to act for me in an emergency or accident/illness.

Email

This field is for validation purposes and should be left unchanged.