“Sports and Disabilities – Opportunities and Awareness” A WorldChicago Exchange Program for Brazil and the United States Sponsored by the US Department of State’s SportsUnited Office July 17 – 27, 2013
US Student Application APPLICATION DEADLINE – May 24, 2013
Program Introduction and Application Instructions WorldChicago’s “Sports and Disabilities – Opportunities and Awareness” Exchange Program in 2013 will bring 14 students and 6 adults from Brazil to Chicago for a 10 day program from July 17 to 27. The program will also include 6 students from the Chicago Metropolitan Area.
This US Department of State sponsored program will focus on physical fitness education and athletic training for the program participants, and workshops on leadership, advocacy, and the role of volunteerism in increasing opportunities for people with disabilities in Brazil and the United States.
The program will provide an opportunity for US student participants to develop their leadership and advocacy skills, participate in sports activities, enhance their cross cultural communication skills, and learn about Brazilian culture. Through participation in the program, US and Brazilian students will be charged with developing a collaborative project aimed at making a positive impact on sports opportunities for youth with disabilities in the United States and Brazil.
Student applicants for the program should be between the ages of 16-19 years old and demonstrate an interest in community service and sports. All program costs (downtown lodging at Roosevelt University, meals, transportation during program, cultural activities) are covered through the program. Adult leaders from the Chicago Metropolitan area and Brazil will serve as chaperones throughout the 10 day program (both days and nights). Program Timeline & Outline
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
July 17 July 18 July 19 July 20
International AM – initial team 9 am – 1 pm Civic Arrival action planning Judd Goldman Education session Adaptive programming University Sailing/RIC with Volunteer Center Check-in PM – Advocacy sports at Project training Harbor
July 21 July 22 July 23 July 24 July 25 July 26 July 27
Cultural Sports Sports Physical Sports Physical Civic Program International Day Physical Education Education Education/Advocacy Evaluation Departures for Fitness Training Training Wrap-up sessions Session Brazilian Education students (Chicago 2 pm- students Partners depart) of the Americas Welcome picnic Free Night Summer Evening – w/travel Evening – Picnic Chicago delegation & Program White Sox paralmpians Closing Dinner Game
Application Submission Instructions Applications should be submitted by email, mail or fax.
Applications submitted by email should go to [email protected]. By fax, (312)254-1805 or by mail;
WorldChicago 72 E. Randolph Street – 2nd Floor Chicago, IL 60601 Application Questions Application questions should be directed to John Baum at WorldChicago: John Baum Associate Director – Programs WorldChicago (312)254-1800 ext. 100; [email protected] STUDENT BACKGROUND INFORMATION
STUDENT INFORMATION NAME
(As it appears on gov’t ID) Last First Middle First name as it would appear on nametag PERMANENT STREET ADDRESS
CITY, STATE, ZIP CODE
PERMANENT PHONE
MOBILE PHONE
DATE OF BIRTH (mm/dd/yyyy)
PLACE OF BIRTH
COUNTRY OF CITIZENSHIP
GENDER Male Female How did you first hear about the exchange program? (Please be as specific as possible.)
Do you have a passport? If so, please include a photo copy of the bio data page (the page with your picture and passport number on it) along with your completed application. (Yes) (No)
SCHOOL INFORMATION
SCHOOL CURRENTLY ATTENDING SCHOOL ADDRESS
SCHOOL GRADE
Have you ever lived and/or studied outside of the United States? YES NO If yes, please provide a brief description including dates and location.
LANGUAGES
What is your native language?
List other languages you may have. Language Number of years studied Language Number of years studied Language Number of years studied
PARENT/ GUARDIAN INFORMATION
Note: Please attach the signed Parent/Guardian approval form. Make sure to fill out the form at the end of this application.
Parent/Guardian 1 NAME/RELATION TO YOU ADDRESS
TELEPHONE & EMAIL
Parent/Guardian 2 NAME/RELATION TO YOU ADDRESS
TELEPHONE & EMAIL DISABILITY INFORMATION:
Please describe the nature of your disability or list any information here that would be helpful in program planning
Assistive devices you will be traveling with (for planning transportation and sports program needs.)
Comments/Details APPLICATION QUESTIONS:
1. Are you currently engaged in sports? Please explain below what sports you are involved in.
2. Are you involved in community service in your home community? Please provide examples of community service projects or other extracurricular activities you are currently involved in the boxes below.
Number of Number of years Activity/ Description hours per participated in week 3. Please provide an example of a time when you took a leadership role on a sports team, an extracurricular activity, or a community service project.
4. What knowledge and skills do you hope to gain as a result of participating in this exchange program? 5. What do you hope to learn from your Brazilian youth partners in this program? What would you like to share with them?
6. What types of activities do you think youth can engage in to increase opportunities for people with disabilities? PARENT/GUARDIAN AND PARTICIPANT AGREEMENT
“Sports and Disabilities – Opportunities and Awareness” A WorldChicago Exchange Program for Brazil and the United States Sponsored by the US Department of State’s SportsUnited Office July 17 – 27, 2013
All applicants must submit a signed parent or legal guardian form with their application giving permission to participate in the Brazil – US Sports and Disabilities Leadership Program Without a signed form from a parent or legal guardian, the application will not be considered.
I agree that all of the information in this application is true and I agree that if chosen to participate, the applicant will participate in ALL program activities in the United States.
Applicant Signature Date
Parent/Guardian Printed Name Date
Parent/Guardian Signature Date