PERSONAL DATA 

 

Name______________________________________________________________M   F

                  Last                                 First (Given)                                                 Middle

 Mailing Address______________________________   Birth Date________________

                                    Street Address                                                             Day    Month     Year

 ______________________    __________________          ________________________

City                                                                         Country                                               City of birth

Nickname/Name you prefer ____________________Email________________________

Your home phone number___________________

 Your cell phone number _____________________ Facebook address________________

 Age________ Current grade level _______  of  _____________total grade levels.

 Do you have a passport? _____Passport number______________Expiration date_______

 Number of siblings

           Name                                                    Age                            Live at home?

            1._________________________       _______   M  F        __________________

            2._________________________       _______   M  F        __________________

            3._________________________       _______   M  F        __________________

            4._________________________       _______   M  F        __________________

            5._________________________       _______   M  F        __________________

            6._________________________       _______   M  F        __________________

 Father’s full name_________________ Mother’s full name________________________

 Address__________________________ Address________________________________

 City ________________State _______   City ____________________ State__________

 Email___________________________   Email _________________________________

 Occupation_______________________  Occupation_____________________________

 Cell phone________________________  Cell phone_____________________________

Do you currently live with your parents? ________  If not, name of person or guardian

 you live with ____________________________  Relationship  ____________________

 Cell phone number of guardian.______________________________________________

 Why should we select you to participate in our organization?_______________________

 ________________________________________________________________________

 ________________________________________________________________________

 How do you occupy yourself when you have time alone?__________________________

_______________________________________________________________________

 What group activities to you participate in, and how frequently?____________________

 _______________________________________________________________________

Do you play a musical instrument(s)? ________________If so for how long?  _________

What are your favorite subjects in school?  _____________________________________

 Tell us about any extracurricular sports activities you do __________________________

 ________________________________________________________________________

 What are your strengths and weaknesses?  (3 of each)_____________________________

________________________________________________________________________

 ________________________________________________________________________

What future goals do you have about a career/ work/ and or family  __________________

 ________________________________________________________________________

 What jobs, volunteer or paid, have you had outside your home if any?  _______________

 ________________________________________________________________________

 List any achievements or honors you have received.   _____________________________

 ________________________________________________________________________

Religious preference    ________________________      ___________________________

                                        You                                                            Your family 

Religious participation             very active          regular          occasional         never. 

List the languages you have studied and for how long.

                        Language:                               Years studied

                        1. ___________________      ___________________

                        2. ___________________      ___________________

                        3. ___________________      ___________________

                        4. ___________________      ___________________

________________________________________________________________________

 Name of school you currently attend__________________________________________

 Name of school/university you would like to attend______________________________

 Have you travelled outside of Haiti?    Yes     No.  If so where?_____________________

 ________________________________________________________________________

 ______________________________                        _____________________________

Applicant’s signature                                                                              Date

 In the space below write us a letter and tell us a little about yourself and what you are like with your family and friends at your home.  Use traits that describe you.  Are you friendly, shy, calm, responsible, spontaneous, active, organized?