American Youth Leadership Program - Thailand Adult Participant Application 1. Full name (exactly as it would appear on your passport) First: 2. Gender: Middle: Male: Last: Female: 3. Date of birth (month/day/year): / / 4. City/State of birth: / 5. Citizenship (only U.S. citizens are eligible): U.S. Citizen Non-U.S. Citizen 6. Candidate contact information Name of school: Work address: City: State: Zip: State Zip Home address: City: Email (personal): Phone (home): Phone (cellular): Which phone number do you prefer we use to contact you? Work: Cell: What time during the workday is best to contact you? Do you access email regularly? Yes: No: Which email do you prefer we use to contact you? 7. Current position: 8. How long have you been in your current position? Work: Personal: Home: 9. Please describe your work, with specific focus on subject matter you teach relevant to this program (including responsibilities with students and extra-curricular activities). If you do not teach, please describe your engagement with youth, referencing how this work relates to the program goals. 10. Past work experience. Please list positions, employers, responsibilities, and dates of employment. 11. Educational Background. Please specify degrees and training, major or area of training, and year earned. Please include your high school. 12. Please describe your current volunteer experience. Please be detailed, including the type of volunteer activity, the estimated amount of time spent in each activity, positions of responsibility, including memberships in clubs or other service organizations. 4TH FLOOR MANSFIELD LIBRARY | UNIVERSITY OF MONTANA | MISSOULA, MT | 59801| (T) 406.243.2988 | (F) 406.243.2181 Attach additional pages as necessary. This application is available at no charge and can be duplicated. 13. Prior travel experience outside the US (list dates of travel, cities visited, purpose of visit): 14. Do you have a passport? If so, please attach a photocopy of the information page which includes your name and personal information. Please also note the passport number, date of issue, and the expiration date below in case the copy is difficult to read. 15. Please describe any languages other than English that you speak or have studied: Estimate speaking fluency on a scale of 0 (none) to 5 (fluent in business conversations): Estimate written fluency on a scale of 0 (none) to 5 (fluent in reading and writing): 16. Medical, physical, dietary, or other personal considerations. Please describe any pre-existing medical conditions, including any prescription medication you may be taking, or any dietary or personal considerations. Please be sure to specifically list allergies and degree of concern and treatment. This will not affect candidate selection, but will enable us to make any necessary accommodations. Please note that the State Department and the University of Montana encourage participation by candidates with disabilities and have an established history of accommodating participant needs. 4TH FLOOR MANSFIELD LIBRARY | UNIVERSITY OF MONTANA | MISSOULA, MT | 59801| (T) 406.243.2988 | (F) 406.243.2181 Attach additional pages as necessary. This application is available at no charge and can be duplicated. 17. Please write a statement explaining the relevance of your work to the program, similar past programs you have participated in, your potential contributions to the program, and your interest in long-term cooperative relationships with potential Southeast Asian counterparts. (250 word limit) Please attach: One letter of reference detailing your qualifications and skills for this program (may be from your supervisor, colleague, or other professional relationship). Please also list the names, email, and telephone numbers of two other professional references we would be able to contact, should you progress to the oral interview stage of the application process. Reference #1: Name: Email: Phone: Reference #2: Name: Email: Phone: All applicants must answer these questions for safety and security purposes: 1. Have you ever been convicted of a felony (please include instances of deferred sentencing)? Yes: A felony in Montana State Law is defined as a crime for which more than one year in prison may be imposed. No: 2. Have you been subjected to court-ordered confinement for threatening or causing physical or emotional injury to persons or property? Yes: No: 3. Have you ever been required to register as a sexual or violent offender? Yes: No: Signature _________________________ (Electronic signature is acceptable) Date _____________________ Applications are due November 1, 2015. Applications and reference letter must be sent to to Kelsey Stamm ([email protected]) as one email. You will receive a confirmation email following submission. If you have not received a confirmation email from the Mansfield Center within two days of email submission, please call Kelsey: 406-243-2838. Please contact Kelsey if email submission is not possible. 4TH FLOOR MANSFIELD LIBRARY | UNIVERSITY OF MONTANA | MISSOULA, MT | 59801| (T) 406.243.2988 | (F) 406.243.2181 Attach additional pages as necessary. This application is available at no charge and can be duplicated. Adult Participant Selection Criteria: • • • • • • • • • • • US citizen. Teach full-time at a Montana high school (public or private) OR have significant engagement with youth. Interest in Thailand, international engagement, and food security/nutrition/climate change issues. Interest in assisting youth to become productive and responsible members of society. Flexibility, adaptability, and open-mindedness. Strong teamwork, communication, and leadership skills. Ability to enthusiastically support teenage participants. Willingness to serve on student selection committee and complete committee duties in a timely fashion. Plans to remain in teaching positions or other positions of influence on young leaders. Available to attend in-person meeting in Missoula (February 2016) and participate in all monthly webinars (MarchMay 2016). Available to attend pre-departure orientation in Missoula (July 3-5, 2016) and travel to Thailand for 23 days (July 6-30, 2016). Desired Adult Participant Applicant Traits: • • • • • Experience leading international student groups. An academic emphasis or thematic expertise relevant to program theme and/or program goals. Experience working with diverse student populations and/or youth with disabilities. Represent and respect the diversity of Montana. Creative problem-solving skills. Selection Process The selection panel consists of three people: two members of the Mansfield Center staff and one teacher program alumna. A select number of applicants will be invited to an oral interview via Skype or conference call, with final results announced by November 21. • • Please note that if you are selected, there is no financial compensation for your role in the program. Adult Participants are full exchange participants, and will have both program sessions with the youth and will have some separate program activities reserved just for adult participants. Only program participants are able to travel with the participant group to Thailand. A candidate will be considered ineligible if s/he has previously traveled outside the U.S. on any State Department-funded program within the past three years or if s/he has accepted a scholarship for an impending US government-funded exchange program. Should an applicant be accepted for more than one State Department-funded program in this timeframe, s/he must choose between the programs and select only one program in which to participate. Questions pertaining to the application process or program in general can be referred to Kelsey Stamm via email or by phone: 406.243.2838. The Mansfield Center of The University of Montana does not discriminate on the basis of race, color, sex, religion, national origin, age, disability, or veteran status in its programs and activities. 4TH FLOOR MANSFIELD LIBRARY | UNIVERSITY OF MONTANA | MISSOULA, MT | 59801| (T) 406.243.2988 | (F) 406.243.2181 Attach additional pages as necessary. This application is available at no charge and can be duplicated.