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Global Outreach Catholic Exchange Program Barbara Tota-Boryczka, Executive Director
4815 Whitetail Way Appleton, WI 54914
Phone: 920-540-3085 [email protected]
Fr. Larry Seidl, Spiritual Director [email protected]
2020-2021 GLOBAL OUTREACH PROGRAM APPLICATION PART I: STUDENT, PARENT/FAMILY AND SCHOOL PROFILE
STUDENT PROFILE Name (First, Middle, Family): Click or tap here to enter text.
Name you are commonly called: Click or tap here to enter text.
Gender: ☐ Male ☐ Female Date of Birth: Click or tap here to enter text. (Month Write a word, not a number / Day / Year)
Example: January 1, 2002)
Your age when you enter the U.S. to begin the Program: Click or tap here to enter text. Years/Months Address as it should appear on correspondence:Click or tap here to enter text.Street / Number / Postal Code / City
Click or tap here to enter text.Country
Home Telephone: Click or tap here to enter text. City code / Home number
Your Cell Phone: Click or tap here to enter text. City code / Cell number
Your E-mail Address: Click or tap here to enter text.
(This email address must be current as G.O. will communicate with you primarily via email.)
Insert Recent Photo
Have you applied to other Exchange Program(s) for the coming academic year? ☐ No ☐ Yes Were you accepted? ☐ No ☐ Yes If yes, which one(s)? Click or tap here to enter text.
Birthplace: Click or tap here to enter text. City / Country
Citizenship: Click or tap here to enter text.
Country Issuing Passport: Click or tap here to enter text.
Passport Number: Click or tap here to enter text. Expiration Date: Click or tap here to enter text. (Month Write a word not a number / Day / Year)
Religion1) What is your Religion? Click or tap here to enter text.Note: Only practicing Catholic students can be part of the Global Outreach Program.
Pets1) Do you like Pets? ☐ Yes ☐ No2) Can you adjust to a home with Pets? ☐Yes ☐ No3) I have ☐allergies and/or ☐strong fear of household Pets: ☐Dogs ☐Cats ☐Birds ☐Other Click or tap here to enter text.
Special Dietary Needs1) Do you have any special dietary needs (e.g. vegetarian, etc.)? ☐ No ☐Yes
If yes, please explain: Click or tap here to enter text.
2020-2021 Student Application Page 1 of 14
Global Outreach Catholic Exchange Program Barbara Tota-Boryczka, Executive Director
4815 Whitetail Way Appleton, WI 54914
Phone: 920-540-3085 [email protected]
Fr. Larry Seidl, Spiritual Director [email protected]
PARENT and FAMILY PROFILEParent or Legal Guardian #1☐ Father ☐ Mother☐ Legal Guardian Relationship Click or tap here to enter text.
Last Name: Click or tap here to enter text.
First Name: Click or tap here to enter text.
Middle Initial: Click or tap here to enter text.
Age: Click or tap here to enter text.
Address:Street: Click or tap here to enter text.
Number: Click or tap here to enter text.
Postal Code: Click or tap here to enter text.
City: Click or tap here to enter text.
Country: Click or tap here to enter text.
Home Telephone: Click or tap here to enter text.
Cell Phone: Click or tap here to enter text.
E-mail: Click or tap here to enter text.
Occupation/Profession: Click or tap here to enter text.
Work Telephone: Click or tap here to enter text.
Work Email: Click or tap here to enter text. Religion: Click or tap here to enter text.
Your Family: Include all members of your family, including brothers and sisters who do not live at home
Parent or Legal Guardian #2☐ Father ☐ Mother☐ Legal Guardian Relationship Click or tap here to enter text.
Last Name: Click or tap here to enter text.
First Name: Click or tap here to enter text.
Middle Initial: Click or tap here to enter text.
Age: Click or tap here to enter text.
Address:☐ Same as Parent 1 / Legal GuardianIf different – Complete Address informationStreet: Click or tap here to enter text.
Number: Click or tap here to enter text.
City: Click or tap here to enter text.
Postal Code: Click or tap here to enter text.
Country: Click or tap here to enter text.
Cell Phone: Click or tap here to enter text.
E-mail: Click or tap here to enter text.
Occupation/Profession: Click or tap here to enter text.
Work Telephone: Click or tap here to enter text.
Work Email: Click or tap here to enter text.
Religion: Click or tap here to enter text.
Persons In Your Family Age Gender Live in Your Home
Relationship(Parent, brother, grandparent, etc)
Click or tap here to enter text. Click or tap here to enter text. ☐M ☐F ☐Yes Click or tap here to enter text.
Click or tap here to enter text. Click or tap here to enter text. ☐M ☐F ☐Yes Click or tap here to enter text.
Click or tap here to enter text. Click or tap here to enter text. ☐M ☐F ☐Yes Click or tap here to enter text.
Click or tap here to enter text. Click or tap here to enter text. ☐M ☐F ☐Yes Click or tap here to enter text.
Click or tap here to enter text. Click or tap here to enter text. ☐M ☐F ☐Yes Click or tap here to enter text.
Click or tap here to enter text. Click or tap here to enter text. ☐M ☐F ☐Yes Click or tap here to enter text.
Click or tap here to enter text. Click or tap here to enter text. ☐M ☐ F ☐Yes Click or tap here to enter text.
Click or tap here to enter text. Click or tap here to enter text. ☐M ☐F ☐Yes Click or tap here to enter text.
Click or tap here to enter text. Click or tap here to enter text. ☐M ☐F ☐Yes Click or tap here to enter text.
Click or tap here to enter text. Click or tap here to enter text. ☐M ☐F ☐Yes Click or tap here to enter text.
2020-2021 Student Application Page 2 of 14
Global Outreach Catholic Exchange Program Barbara Tota-Boryczka, Executive Director
4815 Whitetail Way Appleton, WI 54914
Phone: 920-540-3085 [email protected]
Fr. Larry Seidl, Spiritual Director [email protected]
EMERGENCY CONTACT
Name: Click or tap here to enter text.
Relationship: Click or tap here to enter text.
Address: Street: Click or tap here to enter text.
Number: Click or tap here to enter text.
City: Click or tap here to enter text.
Postal Code: Click or tap here to enter text.
Country: Click or tap here to enter text.
Home Phone: Click or tap here to enter text.
Work phone: Click or tap here to enter text.
LIST ANY RELATIVE(S) LIVING IN THE UNITED STATES
Name: Address: Phone:Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text.
Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text.
Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text.
Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text.
Have You Visited the United States ☐ No ☐Yes If yes, please explain: Click or tap here to enter text.
2020-2021 Student Applicatioin Page 3 of 14
Global Outreach Catholic Exchange Program Barbara Tota-Boryczka, Executive Director
4815 Whitetail Way Appleton, WI 54914
Phone: 920-540-3085 [email protected]
Fr. Larry Seidl, Spiritual Director [email protected]
SCHOOL INFORMATION
School Name Currently Attending: Click or tap here to enter text.
School Address as it should appear on correspondence:Street Number
Click or tap here to enter text. Click or tap here to enter text.
Postal Code City Click or tap here to enter text. Click or tap here to enter text.
Country: Click or tap here to enter text.
Phone: City Code Click or tap here to enter text. / Number Click or tap here to enter text.
Anticipated Graduation Date: Month/Year Click or tap here to enter text.
Total Years of School Completed: Click or tap here to enter text.
Your current year in school: U.S. equivalent: ☐9 ☐10 ☐11 ☐12
Headmaster /Principal Name: Click or tap here to enter text.
Class Teacher Name: Click or tap here to enter text.
English Teacher Name: Click or tap here to enter text.
Pastor/Chaplain Name: Click or tap here to enter text.
PART II: STUDENT INFORMATION2020-2021 Student Applicatioin Page 4 of 14
Global Outreach Catholic Exchange Program Barbara Tota-Boryczka, Executive Director
4815 Whitetail Way Appleton, WI 54914
Phone: 920-540-3085 [email protected]
Fr. Larry Seidl, Spiritual Director [email protected]
Your responses to all questions should be thoughtful, truthful, and detailed. Space for your answers will be added as you type.
A. MOTIVATION AND INTEREST IN GLOBAL OUTREACH PROGRAM
1. How did you learn about the Global Outreach Program? Please include names of any alumni, teachers, family members or friends who told you about the Program. Click or tap here to enter text.
2. Give your three most important reasons why you chose to apply to the Global Outreach Program.a. Click or tap here to enter text.
b. Click or tap here to enter text.
c. Click or tap here to enter text.
3. What are the most important challenges or problems facing the Catholic Church in your country? Click or tap here to enter text.
4. Describe your previous experience(s) away from home, without your family, if any. Click or tap here to enter text.
5. How do you feel your society and culture differs from American society and culture? Click or tap here to enter text.
6. What experiences have you had that demonstrate your ability to adapt and be flexible in new situations? Click or tap here to enter text.
7. What will you do to prepare yourself to live for a year in the U.S.? Click or tap here to enter text.
8. At some point, most exchange students feel lonely and homesick. How will you handle those feelings? Click or tap here to enter text.
9. How would a host family benefit by having you as an exchange student in their home? Click or tap here to enter text.
10. If you have a conflict with your host familya. Explain what you will do if your ideas are different.
Click or tap here to enter text.
b. List in order the steps you will use to resolve the conflict.Click or tap here to enter text.
11. What do you expect to gain from your exchange experience? Click or tap here to enter text.
12. When you return home, after completing Global Outreach Exchange Program, what are your future plans in the following areasa. As a student in your current school
Click or tap here to enter text.
b. As a member of your parish Click or tap here to enter text. c. In your future career and vocation
Click or tap here to enter text.
B. SPIRITUAL LIFE AND PERSONAL QUALITIES 1. Have you received the sacrament of Confirmation?
Click or tap here to enter text.
2020-2021 Student Applicatioin Page 5 of 14
Global Outreach Catholic Exchange Program Barbara Tota-Boryczka, Executive Director
4815 Whitetail Way Appleton, WI 54914
Phone: 920-540-3085 [email protected]
Fr. Larry Seidl, Spiritual Director [email protected]
2. If you have not been Confirmed a. Are you planning to receive the sacrament? Click or tap here to enter text.b. Do you have plans to prepare for Confirmation and if so, what are they? Click or tap here to enter text.
3. How often do you attend Massa. On Sunday? Click or tap here to enter text.b. During the week? Click or tap here to enter text.
4. Describe your prayer life outside of Mass. (Daily prayer, retreats, spiritual community participation, etc.) Click or tap here to enter text.
5. Describe your involvement (if any), in the past two years a. Parish Activities
Click or tap here to enter text.b. Volunteer activities
Click or tap here to enter text.
c. Job or work experience Click or tap here to enter text.
d. Clubs or organizations, if anyClick or tap here to enter text.
6. Click on the ( ☐ ) to check the following qualities or personality traits that best describe you.☐ Serious☐Polite☐Optimistic☐ Calm☐Friendly☐Sensitive☐ Faith-filled☐Talkative☐Appreciative
☐Shy☐Quick-tempered☐Casual☐Neat☐Spontaneous☐Adaptable☐Helpful☐Humorous☐Giving
☐Responsible☐Emotional☐Reserved☐Formal☐Active☐Quiet☐Observant☐Thoughtful☐Tolerant
☐Traditional☐Informal☐Compassionate☐Adventurous☐Patient☐Insecure☐Open☐Cheerful☐Independent
7. Which qualities or personality traits that best describe you, as noted above, do you most value in yourself? Why? Click or tap here to enter text.
8. Do you sing and/or play a musical instrument? ☐ No ☐ Yes If yes, which one(s)? Click or tap here to enter text.
9. Choose five favorite interests - in order of preference - with “#1” being most preferred
Reading Computers Cinema/Movies Singing
Hiking Cooking Crafts
Billiards/Pocket Pool Discussing ideasSocial datingDiscussing politics
Drama/Theater Photography/Video Stamp/Coin collecting Camping/Backpacking
2020-2021 Student Applicatioin Page 6 of 14
Global Outreach Catholic Exchange Program Barbara Tota-Boryczka, Executive Director
4815 Whitetail Way Appleton, WI 54914
Phone: 920-540-3085 [email protected]
Fr. Larry Seidl, Spiritual Director [email protected]
Dance: BalletDance: Social/ballroomDance: Modern/jazz Drawing/Painting
Playing an instrument Watching televisionChess/Backgammon Board games/cards
Gardening Watching sportsMusic-classical Music-contemporary
Museums/Galleries Sewing/Needlework Scouting
Other: write in below
1. Click or tap here to enter text.
2. Click or tap here to enter text.
3. Click or tap here to enter text.
4. Click or tap here to enter text.
5. Click or tap here to enter text.
10. Describe your use of technology (computer, tablet, smart phone (texting, apps, etc.), video games, videos or social media). How much time per day/week do you spend for each?Click or tap here to enter text.
11. Indicate four favorite sports in order of preference with “#1” being most preferred.
U.S. Football Field Hockey Golf
Sailing Tennis Table Tennis Soccer
Horseback RidingBadminton Fishing Roller SkatingRoller BladingTrack/RunningBaseball
Ice HockeySnow Skiing Snow BoardingVolleyballBasketballGymnasticsIce Skating
Skiing BicyclingHikingMartial ArtsSwimmingWindsurfingOther: Write in below
1. Click or tap here to enter text.
2. Click or tap here to enter text.
3. Click or tap here to enter text.
4. Click or tap here to enter text.
12. List any special recognition and/or awards you have receiveda. Activities (not academic awards) Click or tap here to enter text.b. Academic Awards or Honors Click or tap here to enter text.c. Outstanding Achievement Awards Click or tap here to enter text.
13. What is your most important accomplishment so far? Why was it important to you? Click or tap here to enter text.
14. God gives each of us unique gifts a. What are the unique gifts that God has given to you? Click or tap here to enter text.b. How will you use your gifts as a Global Outreach Program student? Click or tap here to enter text.
15. What kinds of activities do you generally do with your family? Click or tap here to enter text.
16. In what activities would you like to be involved with during your exchange yeara. Your host family Click or tap here to enter text.
2020-2021 Student Applicatioin Page 7 of 14
Global Outreach Catholic Exchange Program Barbara Tota-Boryczka, Executive Director
4815 Whitetail Way Appleton, WI 54914
Phone: 920-540-3085 [email protected]
Fr. Larry Seidl, Spiritual Director [email protected]
b. In your school during your exchangeClick or tap here to enter text.
17. What household chores and/or responsibilities do you have as a member of your family? Click or tap here to enter text.
C. FOREIGN LANGUAGES SPOKEN AND/OR STUDIEDPlease describe years of study and proficiency in foreign languages you speak and/or have studied.
Language Years of StudyProficiency
Fair Average Good Excellent Fluent
English Click or tap here to enter text.
☐ ☐ ☐ ☐ ☐
Click or tap here to enter text. Click or tap here to enter text.
☐ ☐ ☐ ☐ ☐
Click or tap here to enter text. Click or tap here to enter text.
☐ ☐ ☐ ☐ ☐
Click or tap here to enter text. Click or tap here to enter text.
☐ ☐ ☐ ☐ ☐
2020-2021 Student Applicatioin Page 8 of 14
Global Outreach Catholic Exchange Program Barbara Tota-Boryczka, Executive Director
4815 Whitetail Way Appleton, WI 54914
Phone: 920-540-3085 [email protected]
Fr. Larry Seidl, Spiritual Director [email protected]
STUDENT LETTER TO HOST FAMILYYour letter is a very important part of your application, as it is your opportunity to reveal your personality. Your host family is interested in learning about you in order to prepare for your stay with them. Please describe yourself and your family. Tell why you want to participate in the Global Outreach Program in the United States, and what you expect to learn. Include interests and activities you would like to share with your host family during your stay. Make your letter friendly and personal. This is also a good time to express your appreciation in advance for being invited to become a member of their family. Your letter should be approximately one page in length, and written by you with no assistance from anyone else. This does not need to be written in perfect English – content is most important. Please type on computer.
Click or tap here to enter text.
2020-2021 Student Application Page 9 of 14
Global Outreach Catholic Exchange Program Barbara Tota-Boryczka, Executive Director
4815 Whitetail Way Appleton, WI 54914
Phone: 920-540-3085 [email protected]
Fr. Larry Seidl, Spiritual Director [email protected]
STUDENT PHOTOSAttach three recent, small photographs of yourself in your home with your family, you with friends, and you in your community. These will help your host family understand what your life is like in your home country. Describe each photo in the space provided.
Click or tap here to enter text.
Click or tap here to enter text.
2020-2021 Student Application Page 10 of 14
Global Outreach Catholic Exchange Program Barbara Tota-Boryczka, Executive Director
4815 Whitetail Way Appleton, WI 54914
Phone: 920-540-3085 [email protected]
Fr. Larry Seidl, Spiritual Director [email protected]
Click or tap here to enter text.
2020-2021 Student Application Page 11 of 14
Global Outreach Catholic Exchange Program Barbara Tota-Boryczka, Executive Director
4815 Whitetail Way Appleton, WI 54914
Phone: 920-540-3085 [email protected]
Fr. Larry Seidl, Spiritual Director [email protected]
Parent QuestionnaireThe following questions are to be completed by the parents / legal guardian. This does not need to be written in perfect English – content is most important. Along with your child’s letter to the host family, this information will have much influence on our decision to accept your child into the Program and place him/her with a host family. Please provide detailed information that will help us to understand your child's personality, background, lifestyle, and habits. We ask that you be very frank and honest. Remember that you are writing to another parent, as well as to the Global Outreach staff. Please include information you would want to know if you were going to host their child. Thank you.
1. Who in the family initiated the idea of an exchange with Global Outreach?Click or tap here to enter text.
2. What responsibilities (curfew, chores, behaviors, etc.) does your son/daughter have at home as a member of your family? Click or tap here to enter text.
3. Do you have any restrictions on your son/daughter in regard to social activities?Click or tap here to enter text.
4. Please describe your son/daughter’s personal strengths, qualities, and characteristics. Click or tap here to enter text.
5. What are his/her weaknesses and areas in which growth is needed? Click or tap here to enter text.
6. How does he/she cooperate with authority at home, in school and elsewhere?Click or tap here to enter text.
7. How does your son/daughter express anger and/or frustration?Click or tap here to enter text.
8. How does your son/daughter handle problems?Click or tap here to enter text.
9. What are the hopes and/or expectations you have for your child and his/her exchange experience?Click or tap here to enter text.
10. Please describe the depth of your child’s faith. How does he/she display the quality of his/her faith commitment (e.g. prayer life, service of others, church attendance, etc.)?Click or tap here to enter text.
11. Please describe other information about your child that will help his/her host family to prepare to welcome and care for him/her as a member of their family.Click or tap here to enter text.
Name of Parent)s) / Legal Guardian who responded to the above questions
Click or tap here to enter text. Click or tap to enter a date.
Click or tap here to enter text. Click or tap to enter a date.
2020-2021 Student Application Page 12 of 14
Global Outreach Catholic Exchange Program Barbara Tota-Boryczka, Executive Director
4815 Whitetail Way Appleton, WI 54914
Phone: 920-540-3085 [email protected]
Fr. Larry Seidl, Spiritual Director [email protected]
III. REQUIRED DOCUMENTSA. COPY OF YOUR VALID PASSPORT
a. Your passport must not be expired before you travel and needs to have at least 6 months remaining beyond your date of return to your country
b. Scan your Passport / the page with your picturec. Give the scanned document a title. Include your name in the title so it is easily identified by the
recipient of the document, such asi. Document_YourFamilyNameYourFirstNameii. Example: Passport_TotaBoryczkaBarbara
d. E-mail the scanned copy of your Passport to i. [email protected]
B. COPY OF YOUR VISAa. Scan your Visa – when it is available.b. Give the scanned document a title. Include your name in the title so it is easily identified by the
recipient of the document, such asi. Document _ YourFamilyNameYourFirstName ii. Example: Visa_TotaBoryczkaBarbara
c. E-mail the scanned copy of your Visa to i. [email protected]
d. You may bring the copy of your Visa with you to your G.O. Student Orientation in Wisconsin
C. CERTIFICATE WITH YOUR COURSES/GRADES FROM THE PREVIOUS TWO (2) YEARSa. Provide a copy of the Certificate with your Courses/Grades from your school – translated into Englishb. Scan previous year’s courses/grades, i.e., 2018-2019
i. Give the scanned document a title. Include your name in the title so it is easily identified by the recipient of the document, such as
1. Document _YourFamilyNameYourFirstName2. Example: CourseCertificate2018-2019_ TotaBoryczkaBarbara
ii. E-mail the scanned copy of your previous year’s Courses/Grades Certificate to 1. [email protected]
c. Scan this year’s courses/grades, i.e., 2019-2020i. Give the scanned document a title. Include your name in the title so it is easily identified by
the recipient of the document, such as1. Document _YourFamilyNameYourFirstName2. Example: CourseCertificate2019-2020_ TotaBoryczkaBarbara
ii. E-mail the scanned Courses/Grades Certificate for this year by July 1, 2020 toiii. [email protected]
2020-2021 Student Application Page 13 of 14
Global Outreach Catholic Exchange Program Barbara Tota-Boryczka, Executive Director
4815 Whitetail Way Appleton, WI 54914
Phone: 920-540-3085 [email protected]
Fr. Larry Seidl, Spiritual Director [email protected]
IV. Signatures Please, carefully read the information below. Parent(s)/Legal Guardian and your signature are required.Instructions:
1. Please click in each of the boxes ( ☐ ) stating that you have read, understand, and agree with the information contained on the identified pages of the Global Outreach Student Application form that you have completed.
2. Print the page and sign. After completing the required signatures, scan this page, and include it with your application form. Bring the original with you.
☐ We have read and we understand the Mission, Vision, and Objectives of the Global Outreach Program on Page 3 of the Student Application form.
☐ We have read and we understand the Global Outreach Student Rules and Standards of Contact on Page 4 through Page 6 of the Student Application form.
☐ We understand that by submitting this application to Global Outreach, we agree to support all objectives of the Global Outreach Program, abide by their Global Outreach Student Rules and Standards of Conduct, and fully participate in all required Global Outreach Program activities, including the Summer Camp prior to and immediately following the year of exchange.
☐ We understand that the Global Outreach Program is for one year only and that the Program does not allow a second year of study in the United States for any reason whatsoever as described on Page 6 of the Student Application form.
☐ Permission to Travel: As the legal parents/guardians of the student applying for the Global Outreach Program, we herewith give our full consent for our son/daughter to travel within the United States if accompanied by an adult person approved by Global Outreach (over age 25), or with an approved organization such as a church or youth group, or together with his/her host family. We understand that any travel without the host family must be approved in writing by the host family, and a complete itinerary is to be provided to them. We further understand that our son/daughter will be responsible for any expenses incurred during any trip or excursion. Our son/daughter may not travel while school is in session unless the trip is approved by Global Outreach. (Parent’s signature and approval is required even if the student is over 18 years of age.)
Student’s Signature: ____________________________________________ Date: ____________________
Mother’s /Guardian’s signature: ___________________________________ Date: ____________________
Father’s/Guardian’s Signature: ____________________________________ Date: ____________________
2020-2021 Student Application Page 14 of 14
