Youth Ambassador Application

Application for Membership

MESA SISTER CITIES ASSOCIATION
P. O. BOX 5572
Mesa, Arizona 85211

Mission: To promote international friendships through mutual respect, understanding, and cooperation, one individual, one community at a time in order to créate long-standing international relationships.

Mesa Sister Cities: Burnaby, Canada; Kaiping China; Guaymas, Mexico; Upper Hutt, New Zealand; and Caraz, Peru

This application has several components. It is helpful to gather all of the information together before you begin the application process. You will need:
- Student Personal Assessment Essay
- Guardian’s Statement and Description of Student
- A recent picture/headshot
- Teacher Recommendation Letter – download here
This form has a “save and continue” feature so that you can begin the form, save it and continue work later on. To enable, scroll to the bottom of the page and click “save and continue”. You will receive an email with a link. It is very important to save that link so you can come back into the form and continue completing the application.
Student Information
Date*
MM slash DD slash YYYY
Name*
First Middle Last
Nickname
Permanent Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone
Cell Phone*
Email*
Hidden
Sex*
Height*
Gender*
- Male
- Female
- gender variant/ non-conforming
- not listed
- prefer not to answer
Birth Date*
MM slash DD slash YYYY
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?*
Guardian 1 Information
Full Name*
First Middle Last
Hidden
Father Living or Deceased
- Living
- Deceased
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
Guardian 2 (if applicable)
Full Name
First Middle Last
Hidden
Mother Living or Deceased
- Living
- Deceased
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/Guardian Input
Guardian 1 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.
Guardian 2 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.
Teacher Recommendation Letter
Please have one of your teacher’s fill out this letter of recommendation then upload it here.
Drop files here or

Max. file size: 50 MB, Max. files: 3.
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.
Name
This field is for validation purposes and should be left unchanged.

Save and Continue Later

Youth Ambassador Application

Application for Membership

Youth Ambassador Application

Student Information

Tell us more about you…

Guardian 1 Information

Guardian 2 (if applicable)

Family and Travel

Essay

Parent/Guardian Input

Find Us

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Language	How Long

Name	Age

Name	Age

Location	Approximate Dates	How Long