Indonesia Youth Leadership Program

INDONESIA
Student Application
This Application is free of charge and may be duplicated.
Application Deadline:January31, 2017
Program Description:Secondary school students (ages 15-17) and educators
(teachers/community leaders) from Indonesia are invited to apply for participation
in Indonesia Youth Leaderhsip Program On Demand 2017. The program will be
intensive, academic, and interactive. As such, the program sponsors seek energetic
applicants who are ready to develop their skills in order to be effective leaders in
their schools and communities. Adult participants in this program take on a unique
role as a participant role model as well as chaperone, and as an active program
participant. We expect the adult participants to be fully engaged in program
activities while also serving as a liaison between youth participants and program
staff, should problems arise.
Secondary school students who may apply are those who:
Will be at least 15 years old and not more than 17 years old by July01, 2017
Have a high school graduation year of 2018 or later
Have fluent English skills
Have permission from parent(s)/guardian(s) and schools to participate in the
entire program
Instructions for completing this application: Please fill out the application as
completely as possible, in English. The information you provide on this application
will provide the basis for selecting semi-finalists for this program. Answer the
questions carefully and completely.

This Application is free of charge and may be duplicated.

Applications should be submitted to Irmina Reniarti (Reni), U.S. Embassy Jakarta, Jl.
Medan Merdeka Selatan 3 5 Jakarta Pusat, Tel: 021-34359535, fax: 021-3520144.
Email: reniartii@state.govQuestions regarding the application and selection process

Indonesia Youth
Leadership Program On Demand 2017
should be addressed to the contact above.

Student Application
About you:
Last (Family) Name ____Az-zahra_____________________________
First Name _______Priscilia_________________________________
Middle Name ______Balqis ________________________________
Nickname ___Balqis______________________________________
Male _______

Female ________

Age as of July01, 2017

___17th years old______

Birth date: Day __27_____

Month ______april_______________________ Year

_2000____________
Address_____Sisingamangaraja street alley sarikam kav.famili no.
7A__________
City, Postal Code__Bandar lampung,35114_________________
Mobile Phone _083170379081__________________
Email ____balqispriscilia@gmail.com__________________________
City/Town and Country of Birth ___Bandar Lampung/
Indonesia________________
Country of citizenship or permanent legal
residence___Indonesia________________
About your family:
Parent or guardian name(s) _Grand father

: Djohan Bin M

Suit______________________
_Grand mother : Salmah ____________________________

This Application is free of charge and may be duplicated.

Address (if different from yours) ______________________________________

Father/Guardian: Mobile Phone _082176591890______ Email
_________________________
Mother/Guardian: Mobile Phone __083807559570___Email
________________________
Occupation of your parents/Guardians:
___entrepreneur__________________________________
Brother(s)/Sister(s)
Name
Gender
Age
Occupation
th
_Bianca Aura_____________Female_________ 8 years old____elementary
student
_____________________________________________________________________________
_____________________________________________________________________________
About your education:
School name_SMA Negeri 7 Bandar Lampung_____________________
School address_Teuku Cik Ditiro street no. 2 Beringin raya, kemiling_______
City/Town/Province, Postal code__Bandar Lampung/ Lampung____________
Current grade _eleven___

Year you will graduate _____2018______________

How many years have you studied English? ___12 years___________

Do you speak any other languages besides your native language and
English? Which ones?
_______Deutsch______________________________________________________
About youracademic and community interests:
Academic subjects you are most interested in: ___civic___________
Please describe the activities (extracurricular, community, hobbies) in which
you have participated, how long you have been involved with each, any
awards or honors. Use additional space as needed.
I am interested in material art, especially Karate. I joined karate for 10 years.
Ive attended many provincial and national competitions. My biggest
achievement was represent the province of Lampung in the prestigious
competition. Not everyone could follow, but I had the twice in a row. The
competition was Olimpiade Olahraga Siswa Nasional (O2SN). Although I
This Application is free of charge and may be duplicated.

failed in the competition, but Ive got a lot of valuable lessons. I never give
up with it. Because of that I became more motivated and practice more to
join other competitions. And then in other competition I often became a
champion in my competitions.

Future studies and/or possible occupations you have considered:

_Psychologist/Human resources development (HRD)____________

Can you identify a specific issue or problem affecting your school,

neighborhood, or community? What might you do to help resolve this
problem?

Please respond to the following short essay questions (e.g., 1/3 to 1/2 page
responses).
o

Why is participation in this program important to you?

I really want to visit one of beautiful country like America,I really want to
go there. Because in America was born many great people and a lot of
influence the world. For the example Mark Zuckerberg, he is CEO of
Facebook. With Facebook we can also find out the moment has been
haeppening in this world and we can communicate even with long
distances. I follow this program as well as for my school became a better
This Application is free of charge and may be duplicated.

school because a student became an amabassador for her country. It also

my own will difintely get a lot of valuable lessons in this program. For the
example, I will know what kind of America culture meet new people and
share stories of how their country. From there I will get a lot of lessons for
my self and people around me. Thats way I wanted to join this program.

During this exchange, participants will act as ambassadors for their

countries. What qualities do you have that would help you fulfill this role?

In what ways are you an effective leader? What leadership skills would
you like to improve?

How will your participation in this program benefit your community?

For in America later I will get a lot of lessons for my life, for example how
to adapt to the new environment and situation, get to know the culture of
various countries for meeting new people and much more. Thats where
Ill share things will I get for my community. And the main things is the
school I became better as creating student achievement, because at my
school are not many who follow a program like this, with my school it will
be an example for other school because possessed outstanding students.

Is there anything else you would like us to know about you?

This Application is free of charge and may be duplicated.

More about you:

Do you have a valid passport? ___No____
If yes:

Issuing Country ____________________________

Passport Number ________________ Expiration Date (day/month/year)

__________________
Have you ever lived, visited and/or studied in the United States or in another
country? _____No_____
If yes: Where, when, why?
______________________________________________________

Applicant signature:
All information in this application is accurate and true
__________________________________________________

Date _____________

Parent/Guardian signature(s):
I permit my child to apply for and, if selected, to participate in this program.
__________________________________________________

Date _____________

__________________________________________________

Date _____________

This Application is free of charge and may be duplicated.

INDONESIA YOUTHLEADERSHIP PROGRAM ON DEMAND

2017
Reference
For the Applicant: Below, fill in your name and give this form to a teacher or other
adult outside your family who knows you well. Ask the reference to fill out the form
and return it with all the forms above.The answers to the questions in the form do
not need to be written in English.
Applicant Name (write in your name)
_____________________________________________________
For the Reference: The student named above is applying to take part in the
Indonesia Youth Leadership Program, a three-week exchange program in the United
States for students and teachers/community leaders. The selected students will be
in a challenging academic environment and intensive leadership training. To
succeed, the participants must be highly motivated, and be able to adjust to living
and working with people of different social and cultural backgrounds. We value your
honest assessment of the applicant in helping us select the most appropriate
participants. If you would like to add additional comments, we encourage you to do
so. Your answers will remain confidential.
Please indicate your opinion of this applicants ability to meet the challenges of this
program
_____ I strongly recommend this student
_____ I recommend this student
_____ I have minor reservations about recommending this applicant
_____ I have major reservations about recommending this applicant
_____ I do not recommend this student
How long, and in what context or capacity, have you known this applicant?
2 years, as an English labolatory in her school.
What are the applicants strengths?
She has high motivation in English,always want to know about English.
What are the academic or personal areas in which this applicant needs
improvement?
Please describe the applicants behavior or attitude with respect to authority, peer
relationships, responsibility, and work activities.
I think she has good behavior, eventhough she always keep calm in class, but in do
work/task she can do it.
Do you think the applicant would adapt well to unfamiliar environments and new
situations? Why or why not?

This Application is free of charge and may be duplicated.

Yes, I think she can adapt with new situation, because she has good attitude in
relationship at new situation.
Name (printed) ___Marlina Zainal, S.Pd__________________________
Signature _______________________________________ Date ___ January, 13th 2017___

This Application is free of charge and may be duplicated.