Student and parent(s) signatures are required on both documents using black ink. Bring completed original application with you to the U. S. and give to the Executive Director


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NameStudent and parent(s) signatures are required on both documents using black ink. Bring completed original application with you to the U. S. and give to the Executive Director
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Global Outreach

4815 Whitetail Way Appleton, WI 54914

920-734-5967 or 920-540-3085

boryczkabb@sbcglobal.net

www.globaloutreachprogram.com

STUDENT APPLICATION 2014 - 2015

Application Instructions:

  1. Carefully read the Mission Statement and Objectives of the Global Outreach (G.O.) Program, as well as the Student Rules and Standards of Conduct. Student and parent(s) signatures are required on both documents using black ink. Bring completed original application with you to the U.S. and give to the Executive Director.

  2. Applications should be done on the computer and typed.

  3. Pages requiring signatures (black ink) should be scanned and included with your application.

  4. Your responses to all questions should be thoughtful, truthful, and detailed.

  5. Your letter to your host family is a very important part of your application. Take time to compose it with thought. It should be written in English without assistance from anyone else.

  6. Submit your application with all other required documentation to your local G.O. Representative.

  7. Application should be e-mailed by you or a local G.O. representative to both directors at:

barbara.tota-boryczka@globaloutreachprogram.com and ljseidl1949@gmail.com . Use PDF format.

  1. Recommendations are confidential. Your teachers and headmaster need to send them to us by mail or e-mail separately.


Application Contents:




Document

Page

To be completed and/or signed by



G.O. Mission, Vision, and Objectives

2

Student and Parent(s) / Guardian



Student Rules and Standards of Conduct

3-4

Student and Parent(s) / Guardian



Student Agreement –One Year Program

5

Student and Parent(s) / Guardian



Student Demographic Page

6

Student and Parent(s) / Guardian



Parent Information

7-8

Parent(s) /Guardian



School Information

9

Student



Student Application

10-15

Student



Student Letter to Host Family

16

Student



Student Photos

17-18

Student



Parent Questionnaire

19-21

Parent(s) /Guardian



Permission to Travel Form

22

Parent(s) / Guardian



Liability Release Agreement

23

Parent(s)/Guardian and Student



Insurance Coverage Form

24

Parent/Guardian



Medical Information

25-27

Licensed Physician



Photocopy of Student Passport-make sure it is valid for the school year

28

Include with the application



Transcripts from previous 2 years

29

Include English translation of transcripts



English Teacher Recommendation

30-31

English Teacher



Class Teacher Recommendation

32-33

Class Teacher



Headmaster Recommendation

34-35

Headmaster or Principal



Pastor Recommendation

36-37

Pastor or School chaplain




To be included with your application:

Notes:



Passport sized photo (approx. 1”x 1½”)

Attach one photo to page 6 of application



Student Insurance Coverage Form and photocopy of medical insurance policy due two weeks after acceptance letter received.

E-mail after your acceptance for the program and bring the original to the 2014 GO Orientation in U.S.


Student Name:
(Print: First Name (Given) / Middle Name / Family Name)

The GLOBAL OUTREACH Program

MISSION:

Global Outreach is committed to the building of a civilization of love in Central/Eastern Europe as well as in the United States through the formation of young Catholic leaders who are committed to rebuilding the Church.
VISION:

Global Outreach achieves its mission by means of Catholic student exchanges between high school and other Church organizations in the U.S. and Central/Eastern Europe.
In addition to the values of cultural sharing and personal growth, Global Outreach encourages students to grow in their Christian faith and servant leadership abilities with a commitment to the vision of building a civilization of love. The program supports the students in their efforts to grow as persons, becoming healthier, wiser, freer, more autonomous and more likely to become servants, especially of those who are least privileged in society.
Global Outreach also seeks to promote links between Catholic leaders and institutions in Central/Eastern Europe and the U.S., helping them to grow in their efforts to build a civilization of love through the renewal of the Catholic Church and its commitment to the new evangelization.
PROGRAM OBJECTIVES:

Each student will attend a Catholic high school in the US for a full academic year (junior status) while living with a Catholic family. He/she will participate in school, parish, and community activities, especially youth ministry programs, and will share his/her culture, faith, and talents. Specific objectives for each student are:

  1. To successfully complete one academic year in an American Catholic high school, and we highly recommend that students

    1. Participate in and successfully complete a course in speech, and develop good oral communication skills

    2. Participate in and successfully complete English courses which encourage the development of a well-rounded use of the English language, including grammatical usage, reading, writing, and interpersonal communication

    3. Participate in and successfully complete a course in American History

    4. Participate in and complete a course in computer literacy and/or keyboarding

    5. Participate and successfully complete the required Religious Studies course

    6. Participate in the school’s campus ministry program and, if possible, a Teens Encounter Christ (TEC) weekend

    7. Share and participate in at least one school extracurricular activity

    8. Sign up for and successfully complete one or more other courses for enrichment which might not be part of the curriculum back home




  1. To learn about, adapt to, and participate in an American Catholic Christian family’s life and activities

    1. Participate in parish life through available activities, such as choir, youth groups, festivals, child care, and liturgical ministry

    2. Participate with their families in community activities such as community projects, holiday celebrations, and volunteer opportunities, and become familiar with their surroundings, ex. public transportation, shops, areas of interest, etc.




  1. To share their native culture, their faith, and their individual talents with their host families, schools, and parish and civic communities

    1. Examples are: speaking in classrooms and at parish and club meetings; participating in cultural fairs; talking with individuals; using musical, theatrical, and leadership talents; participating in retreats; and sharing information about the Global Outreach program




  1. To return to their countries with an intent to participate in parish and community as Christian servant leaders

    1. Participate in and provide leadership at the Global Outreach Summer Camp during the summers, both prior to the exchange and immediately following the student’s return home from the United States

    2. Other examples are: being active in youth organizations; encouraging others to participate in Global Outreach; participating in alumni activities in the Global Outreach program; sharing their understanding of American culture as expressed in family life, parish life, schools, and civic organizations; volunteerism; and active participation in their parishes


We have read and we understand the Mission, Vision, and Objectives of the Global Outreach program.
Student’s signature: Date:
Mother’s / Guardian’s signature: Date:
Father’s / Guardian’s signature: Date:

Student Rules and Standards of Conduct
Global Outreach expects the highest standards of behavior from students at all times. In turn, the Board of Directors and staff of Global Outreach work together to ensure that the student’s exchange experience in the United States is as safe, successful, and enriching for both students and host family as possible. The following Student Rules and Standards of Conduct have been established for that purpose. Violation of these rules will lead to disciplinary action and possible return of the student to his/her home country. Violations of local, state, or federal laws or serious misbehavior in the host family or the community will result in an immediate return to the home country. A student’s return home will be at the expense of the student’s natural parent(s) or guardian(s), with no refund of program fees.
LOCAL, STATE, and FEDERAL LAWS:

  1. The student in the Global Outreach program is not permitted to purchase, possess, or consume any alcoholic beverages. Drinking alcoholic beverages, including beer and wine, is illegal for persons under the age of 21.

  2. Smoking or chewing, as well as purchase or possession of tobacco products, is not permitted for any participant of the Global Outreach program at any time.

  3. The student must not buy, sell, possess, or use illegal drugs of any kind. If the student is taking prescription drugs, the name, dosage, and length of time of use for each drug must be listed on the Global Outreach Medical Form. The student must not associate with any person who engages in any illegal activity, such as drug use and trafficking and/or underage alcohol consumption.

  4. Students are prohibited from accessing, purchasing, possessing and/or viewing pornography or other obscene materials.

  5. The student must not commit or take part in any act of violence against another person or property.

  6. It is illegal for the student to take regular employment while in the U.S. The only exceptions are occasional odd jobs, such as yard work or baby-sitting. Any such jobs must not interfere with activities or objectives of the Global Outreach program, and students must have host family permission.

  7. Because of the danger and liability involved in driving, the student may not drive any motorized vehicle. This includes, but is not limited to, any car, truck, motorcycle, All-Terrain Vehicle (ATV), boat, farm equipment, snowmobile, etc. In addition, the student may not obtain a U.S. driver’s license. The student must wear his/her seatbelt and shoulder harness whenever riding in an automobile.

  8. The student is forbidden to hitchhike at any time, either alone or with companions. It is illegal in most states and extremely dangerous.


YOUR HOST FAMILY:

All Global Outreach host families are volunteers and receive no compensation for hosting a G.O. exchange student. Host families participate in the Global Outreach program because of their sincere desire to share their Christian faith and family life, and to experience other cultures. Host families agree to provide students with a bed and meals and welcome them as a member of their family. The student is not guaranteed a private bedroom, nor placement within a particular community or school.

  1. The student will regard his/her host parents as his/her own, and will respect them and their home in every way. The student will not be staying as a guest in the home, but rather as a family member, and will be expected to comply with all rules of the host family, including curfews, visitors, chores, etc, as is proper and usual in the United States.

  2. The student must receive permission from the host parents to use any device belonging to the host family, such as the telephone, computer, or television. The student must adhere to any rules and time restrictions set on using such devices.

  3. The student is responsible for to pay for all phone calls he/she makes outside the local calling area. We highly recommend that students purchase and use prepaid phone cards to use for their long-distance calls.

  4. The student must receive permission from host parents for any and all activities. The student must keep the host family informed at all times of his/her whereabouts, with whom he/she is associating, and time of departure from and return to the host family’s home.

  5. The student must not borrow money from the host family or from any other source. Natural parents must supply the student with an adequate amount of spending money, normally $100 per month. Students are responsible for all extraordinary expenses, such as non-essential school supplies, entertainment, meals outside of the home, personal expenses, and travel expenses within the United States. The student will establish a bank account separate from that of his host family.

  6. As a responsible Catholic young adult, the student will observe the laws of the Church, including, but not limited to, weekly attendance at Mass.


ACADEMIC LIFE:

A student’s strong academic performance will foster continued support of the Global Outreach program in the host communities and future placement of Global Outreach students. Students are expected to participate actively in academics and extracurricular activities, and display a respectful and appreciative Christian demeanor both in and outside of school.

  1. The student will be enrolled in his/her school as a junior. Since the student will not have met the (four-year) requirements for graduation from a high school in the United States, he/she will not receive a diploma nor will he/she graduate from the high school. Depending upon school policy, the student may receive a certificate of attendance from the school.

  2. The student must attend school daily, maintain a full course load, and obey all school rules and regulations, including dress code and appropriate behavior. The student may not take time off from school except in case of illness or emergency, or by prior written approval by the Director of Global Outreach for a special event.

  3. The student is responsible for all extra school fees, such as yearbook, class photos, student activities, sports equipment, entertainment, etc.

  4. Disruptive behavior, academic failure, or breaking of school rules will be grounds for the student to be sent home at his natural parents’ expense.

  5. The student may not play varsity sports; however, he/she is encouraged to try out for and become involved in intramural and/or junior varsity sports. Placement on a team is not guaranteed but is at the discretion of the high school.


VISITORS AND TRAVEL:

  1. Visits from members of the student’s natural family from his/her home country can be very disruptive to the student’s adjustment to his/her exchange experience, as well as an inconvenience to the host family. Therefore, visits are not recommended until the very end of the program, when the student may arrange to travel back home with his/her natural family. Any visit must be by (prior) invitation of the host family and must have prior approval by the Executive Director.

  2. Likewise, the student is strongly discouraged from visiting relatives residing in the United States for the first six months of their exchange. Written permission from the natural parents, permission of the host family, and a letter of invitation from the family with whom the student wishes to visit, are required prior to any visit. Final permission for the visit is at the sole discretion of the Director of Global Outreach.

  3. The student may not travel back to his/her home country during the exchange. In case of family emergency, the student should contact the Director of Global Outreach for further instruction.

  4. The student may not travel outside his/her local community, either by him/herself or with peers, unless he/she has the permission of the host parent(s).

  5. Out-of-state travel with the host family, another family, an approved group (such as a school or church-sponsored group approved by Global Outreach), or with a responsible adult is permitted only with prior approval from the host family. The host family and Global Outreach must be provided with pertinent information about the trip and contact information in case of emergency.

  6. The student must carry his/her passport whenever traveling by air. If the student wishes to travel with his host family outside of the United States, he/she must have written permission from his/her natural parent(s) or guardian and Director of Global Outreach. Before departing for such a trip, the student must check with U.S. Immigration to be sure that he/she will be allowed to re-enter the United States.


RETURNING HOME:

  1. The student is not allowed to remain in the United States at the conclusion of the exchange program (one-to-two weeks after the end of the academic year) unless prior permission is given in writing by the student’s natural parents and the Global Outreach Board of Directors for adult-supervised travel. A detailed itinerary of travel plans, including modes of travel and all contact information during the travel, must be submitted. The student must maintain adequate insurance coverage.

  2. The student MUST depart the United States prior to the expiration of his/her visa. Students who do not leave the country as noted above, will be reported to the Bureau of Citizenship and Immigration Services as required by law.

  3. The Global Outreach program is for one year only and does not allow a second year of study in the United States for any reason.

  4. The rule of the program is to fulfill one year of study in the United States and return after that year to home country to complete gymnasium/high school education, to share experience as a Global Outreach student with local church, school and country, and to promote the Global Outreach program in those places. Therefore student will not ask the Global Outreach staff and board to extend his/her stay in the United States for an additional year or years of study and will not make any attempts to persuade Global Outreach partner school in the United States to extend studies beyond the one year.


MISCELLANEOUS:

  1. The student must respect and obey all rules and decisions made by the Global Outreach Board of Directors. Failure to do so may result in the student being sent home at his/her natural parent/guardian’s expense, with no refund of program fees.

Student’s signature: Date:
Mother’s / Guardian’s signature: Date:
Father’s / Guardian’s signature: Date:




GLOBAL OUTREACH STUDENT AGREEMENT

ONE YEAR PROGRAM
As a Global Outreach student, I understand that the Global Outreach program is for one year only and that the program does not allow a second year of study in the United States for any reason whatsoever.

I agree to accept and support this rule of the program by fulfilling my one year of study in the United States and returning after that year to my home country to complete my gymnasium/high school education, to share my experience as a Global Outreach student with my church, school and country, and to promote the Global Outreach program in those places.

I promise that I will not ask the Global Outreach staff and board to extend my stay in the United States for an additional year or years of study. I further promise that I will not make any attempts to persuade my school in the United States to extend my studies beyond the one year that it has already agreed to grant me.

I understand that this promise does not deny me the opportunity to return to the United States for college or university studies after my graduation from gymnasium/high school should I desire to do so.


Signature of Global Outreach Student Date



AGREEMENT:

We have read and we understand the Student Rules and Standards of Conduct for the Global Outreach program. Furthermore, we understand that by submitting this application to Global Outreach, we agree to support all objectives of the Global Outreach program, abide by their Rules and Standards of Conduct, and fully participate in all required program activities, including the Summer Camps prior to and immediately following the year of exchange.

Student’s signature: Date:

Mother’s / Guardian’s signature: Date:
Father’s / Guardian’s signature: Date:
Global Outreach

4815 Whitetail Way

Appleton, WI 54914

920-734-5967 or 920-540-3085

boryczkabb@sbcglobal.net

www.globaloutreachprogram.com

STUDENT APPLICATION FORM




Name (First, Middle, Family):
Name you are commonly called (“nickname”):
Male  Female

Date of Birth:

(Month / Day/ Year)
Your age when you enter the U.S. to begin the program:

Years / Months

Address as it should appear on correspondence:


Street / Number / Postal Code / City


Country
Home telephone:

City code / Home number

Your cell-phone:

City code / Cell number

Your email address:
(this email address must be current as G.O. will communicate with you primarily via email)

Have you applied to any other exchange program(s) for the coming academic year?  No  Yes
Were you accepted?  No  Yes If yes, which one(s)?

Birthplace:

City / Country
Citizenship:


Country issuing passport:

Passport number:

Expiration date:

(Month / Day / Year)


Height: Weight: Eyes: Hair:


Religion:
(only practicing Catholic students can be part of the Global Outreach Program)

How often do you attend Mass?

Global Outreach

4815 Whitetail Way

Appleton, WI 54914

920-734-5967 or 920-540-3085

boryczkabb@sbcglobal.net

www.globaloutreachprogram.com
PARENT INFORMATION



Father or Legal Guardian
Last Name:

First Name:

Middle initial: Age:

Address:

Street: Number:

Postal Code: City:

Country:

Home telephone:

Cell-phone:

Email:

Occupation/Profession:

Work telephone:

Work email:

Religion:
Mother or Legal Guardian
Last Name:

First Name:

Middle initial: Age:

Address:

Street: Number:

Postal Code: City:

Country:

Home telephone:

Cell-phone:

Email:

Occupation/Profession:

Work telephone:

Work email:

Religion:


I currently live with:  Father  Mother  Stepfather  Stepmother  grandparent(s)  sibling  other _______


Names of parents and siblings
(or others if they are living in your home)

Age

Gender

Living at home?

Relationship







M F

Yes No

Mother







M F

Yes No

Father







M F

Yes No










M F

Yes No










M F

Yes No










M F

Yes No










M F

Yes No










M F

Yes No










M F

Yes No






Global Outreach

4815 Whitetail Way

Appleton, WI 54914

920-734-5967 or 920-540-3085

boryczkabb@sbcglobal.net

wwww.globaloutreachprogram.com


Emergency Contact:

Name:

Relationship:

Address:

Home Phone:
Work phone:


List any relative(s) living in the United States:

Name: Address: Phone:



Global Outreach

4815 Whitetail Way

Appleton, WI 54914

920-734-5967 or 920-540-3085

boryczkabb@sbcglobal.net

wwww.globaloutreachprogram.com

SCHOOL INFORMATION


School currently attending:



School Name:

School address as it should appear on correspondence:

Street / Number


Country:

Phone:

City code / Number


Anticipated graduation date:

Month/Year


Postal Code / City


Total years of school completed:
Your current year in school:

U.S. equivalent: __9 __10 __11 __12

Headmaster /Principal Name:
Class Teacher Name:
English Teacher Name:
Pastor/Chaplain Name:


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