U.S. Summer Sisters Exchange Program 2017 Application 1- Applicant Contact Information Full Name: Recent Photograph Date of Birth: Not more than six Place of Birth: months old Current Grade Leve E-mail Address: Contact Number (Home): Contact Number (Mobile): II-School Information Name of School: Name of School's Contact Person: E-mail Address: Phone Number (School): Contact Number (Mobile): I1I- Family Information Father's Name: Mother's Name: Father's Job: Mother's Job: Father's E-mail: Mother's E-mail: Father's Mobile: ‘Mother's Mobile: Any Other Source of Income: Yes No _fyes, explain: Home Address: City: Province: Country: Page 1 ofSIV- Travel Information Areyoua citizen of Pakistan? = Yes [No Areyoua citizen of any othercountry? [Yes []No _ Ifyes, name: Have you ever traveled abroad? [Yes [No Ifyes, name: Have you or your family applied for immigration to any country? OYes [No Ifyes, name: Do you have any relatives in the United States? [Yes [No Ifyes, relationship and where they live? V- Academic Interest Please rank your top three choices (1 being the top choice, please): Ranking Fields ‘Arts (literature, theatre, photography, art history, music, ete.) Business (business essentials, finance, marketing, etc) Communication (journalism, writing) Entrepreneurship (for those with business ideas or aspiration to start a company) Foreign language (Arabic, Chinese, French, Greek, Japanese, Latin, Spanish, ete.) International Affairs (cross-cultural communication, international peace and conflict resolution) Leadership (program to empower community leaders and activists) Life Sciences (biology, chemistry, astronomy, physics, environmental science) Pre-Engineering (electrical, computer, biomedical, and systems engineering) Pre-Medical (choose from one of two tracks: research or clinical) ‘Social Science and Humanities (political science, economics, philosophy, religious, cultural, regional studies) Page 20f5VI- Medical Questions Allergies Yes [No Ifyes, explain: Dental problems []Yes [No Ifyes, explain: Physical Disability [Yes [No Ifyes, explain: Orthopedic problems (broken bones) [Yes [No Ifyes, explain: History ofheart disease. [Yes [] No Ifyes, explain: Hospitalizationhistory CjYes [No Ifyes, explain: History of TB Dives [No Ifyes, explain: History of seizures Dyes [No Ifyes, explain: Any other medical history: Page 3 ofSRequired Documents: Youare required to obtain at least one letter of reference from someone in your school who can attest to your qualifications for participation in the program. If you wish, you may also include another letter of reference from a community member who knows you wel. Neither of reference letters can come froma relative or friend. 2. Response to short answer questions listed below 3. Response to essay question listed below 4. Copies of mark sheets from the last three years (2014-15, 2015-16, 2016-17) and NADRA B-Form Short Answer Questions: Ona separate sheet of paper, please write your response to the following questions, Limit your response to approximately 200 words for each question, Please include the question at the beginning of your response. 1. Why does the U.S. Summer Sisters Exchange Program appeal to you, what do you expect to gain from this experience? What do you enjoy learning most about? Which of the programs listed above is your top-choice, and why? Please briefly describe your involvement ties, sports programs, after school clubs/ organizations, or community service, and indicate any leadership roles you have had in these activities. 4. What current or past female leader, in the areas of business, government, education or community service, demonstrates the kind of leader you want to be? Please explain. What are your future career goals and how will participating in this program help you reach your career goal? Essay: Please write an original essay of between 500-1000 words addressing the question belo Identify a problem in your country or community that you feel needs to be addressed. Explain your choice and discuss the opportunities that you have had to either address this issue or learn more about it. How can you as aleader take action to resolve this issue? Page 4 0f5Certification: I/we certily that the information provided on this application is complete and correct to the best of my/ our knowledge, and that if selected the applicant has the consent of her parents to travel to the United States to participate in this scholarship program. Signature of Parent/Guardian Signature of Parent/Guardian Signature and seal of School Official Date: Date: Date: Deadline for Application November 20, 2016 ‘The US. Summer Sisters Exchange Program reserves the right to cancel this scholarship in our sole discretion if we are unable to find qualified students, or if security conditions or any other circumstances warrant cancellation. Completed applications can be submitted to iEARN Centre, iEARN CENTRE ‘88-H, P.E.CHS, Block-6, Near Madani Masjid, Karachi, Sindh, Pakistan. Phone: 021-34547547, 34547549 + Write U.S. Summer Sisters Exchange Program 2017 on the top of the envelope ‘+ Make sure you provide all correct and accurate information. If anything is found incorrect after verification the application will not be accepted. + The acceptance of this form does not ensure the acceptance in the Summer Sisters program, + Visit the web: hitp://www.iearnpk.org/SS/SS.htm for detailed information and updates. Page Sof