China Youth Initiative

2015 Chinese Youth Initiative Application

Chaperone Application
Columbus International Program (CIP)
57 Jefferson Avenue
Columbus, OH 43215-3866
Program Date: June 26-July 8, 2015

www.cipcolumbus.org
(614)221-0034
cipcols@aol.com

I. CONTACT INFORMATION
Family (Last) Name:

First Name:

Middle Name:

Current Mailing Address and Contact Information where CIPUSA correspondence should be sent:
Street & Number
City and State/Province
Postal Code
Country

Telephone

(please include country and city

Alternative telephone number

E-mail

codes)

Permanent Mailing Address and Contact Information

Street & Number
City and State/Province
Telephone

(please include country and city

Postal Code

Fax

Country
E-mail

codes)

II. BIOGRAPHICAL DATA and CURRENT STATUS

Date of Birth (Month/Date/Year)
Country of Citizenship
Gender:
Male

Country of Residence

Have you visited the US before?

Female
Yes

No

If Yes, under what VISA?

If No, under what VISA do you intend to enter the US?

What is your relation to the participant?
List the three activities you would like
to participate in from this program.
1.
2.
3.
How did you hear about this program?

Why are you interested in participating in this program?

III. EMERGENCY CONTACT INFORMATION

In case of an emergency please provide us with information on who to contact:
Name
Telephone
Address

Relationship to You

IV. LANGUAGE ABLITY and INTERESTS

How many years have you studied English?

English Proficiency
Fair

Good

Excellent

V. LIVING ACCOMMODATIONS Applicants are requested to answer the questions below so that the best match can be
provided
between participant.

What type of personality would you consider yourself (please circle as many as applicable):
Independent

Somewhat Independent

Conservative

Extroverted

Dependent

Introverted

Adventurous

Willing to try new things

Do you have any fears or allergies to animals (pets)?

If yes please explain:

Yes

No

(Please circle one)

Do you have allergies to any foods?

Please list foods:
Do you have any dietary restrictions because of your religion that we should be aware of?
Do you smoke?

Yes

No

(Please circle one)

What are your hobbies and leisure interests?

Have you traveled abroad? If so, please describe briefly where and when you traveled abroad.

Have you had or do you have any serious illnesses or disabilities that CIPUSA should be aware of?

VI. DEADLINES
Applications are due by April 26, 2015
Your application will be reviewed by May 5 and letter of approval will be sent by May 7

Chaperone Signature: ________________________________________________ Date: _______________________

*Applications and confirmation of application will be sent via email (Preferred)
If application is sent via postal service: 57 Jefferson Avenue
Columbus, Ohio 43215
United States