LAKESIDE SCHOOL
Global Service Learning
UPPER SCHOOL STUDENT APPLICATION FORM 2010
GENERAL INFORMATION
Name: ________________________________________
Site(s) for which you would like to be considered (Indicate your first and second choice sites):
CHINA ______ DOMINICAN REPUBLIC ____INDIA _____MOROCCO _____ PERU _____
SENEGAL________
Date of Birth: ____________________ Sex: ____________ Grade: _____________
Language _____________________ level ______________ native speaker ___________
Phone Number: ________________________________________
PASSPORT INFORMATION
Full legal name as it appears or will appear in passport (Very Important!):
___________________
___________________
__________________________
First
middle
surname
Passport number: ___________________________________Country of issue: _______________
Date of issue of passport and place issued: ___________________________________________
Date of expiration of passport: ______________________
Your passport must be valid for 6 months after July 1, 2011.
If you have a current passport, please bring in a copy and you may omit filling in this section.
I. PERSONAL STATEMENT
Please write a brief essay addressing the following questions: Why would you like to participate
in this program? How do you feel you are especially qualified to undertake a new culture and new
surroundings?
II. TRAVEL EXPERIENCE
Have you ever lived, studied, or traveled abroad? Please describe your experience (specify countries
visited, purpose of travel, and dates and name of program, if any). Have you traveled within the
United States? When, where and with whom?
III. OUTDOOR TRIP
Have you taken your high school outdoor trip? Yes ____ No _____ If so, where did you go and
when?
IV. SERVICE LEARNING
Service learning involves academic preparation before the trip, work with local people in the target
country on issues they have identified, reflection, and a semester-long service learning project upon
return. What experience have you had with community service or service learning and what do you
value about this kind of learning?
V. RESPONSE TO CHALLENGES
The trip can be a challenge physically and mentally. You will be far from home, in unfamiliar places,
eating different foods, speaking a foreign language, and exposed to different climates. What do you
think will be the single greatest challenge for you? What tools might you use to overcome that
challenge? Describe a physically or mentally challenging experience you have had that made you
uncomfortable and explain how you dealt with it, and what you learned from it.
VI. GROUP EXPERIENCE
Describe a non-classroom group situation you have experienced (outdoor trip, sports team, summer
camp, or other extra-curricular activity). What role did you play? Give a specific example of a
circumstance that highlights this role.
VII. HEALTH AND FITNESS
Describe your general health and fitness level. What kinds of physical activities do you do on a
regular basis? Are you a vegetarian, vegan, lactose intolerant or have other food restrictions? Have
you had any recent injuries or health concerns? Are you currently under the care of a physician or
mental health professional? If so, for what reason? These questions are not meant to exclude anyone
from participation, but rather so we may plan ahead, insure adequate support in the field and perhaps
direct you to the most appropriate site for your circumstances.
VIII. REFERENCES
In order to supplement your written application, we will consult with adults (at least two, and
preferably all, at Lakeside) who know you well. Please write the name of your advisor and two other
adults who could speak to your suitability for this kind of program (advisor, Outdoor Program
leader, coach, classroom teacher, etc.). If non-Lakeside people, please provide phone number.
1. Advisor:________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________
Please email the application and bring a paper copy of the parent/guardian permission
form) to Wendy Russell (wendy.russell@lakesideschool.org) in the main office, by 3:00 p.m.
on November 2, 2010. Save your document with the naming convention
“country11lastnamefirstinitial”, i.e., Peru11DoeJ if your name is John Doe and Peru is your
first choice. Applicants will be notified by mail over Thanksgiving break.
Direct any questions to Vicki Weeks, Director of Global Programs (440-2713).
Please note: A student will be considered for a second Global Service Learning project within a single
division only after all first-time eligible students have been considered and if there is a slot available.