Personal Information
Your first, middle and last name:
Date of Birth (month/day/year):
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
/
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
1986
1987
1988
1989
1990
1991
Sex:
Female
Male
Home mailing address (Street/pob, city, state/country zip code):
Home telephone number (Please include country and city code if from Jordan):
Cell phone number:
Your email address:
How often do you check email?:
every day
every 2 days
once a week
once in 2 weeks
Is there a public-access computer center (youth center, Internet Café, etc.) that you can use in your community?:
Yes
No
If yes, do you know what type of center it is?:
Youth center
Internet Café
Other
Does it have DSL or high speed access?:
Yes
No
How often do you have access to this center?:
Do you have to pay to use this Internetfacility?:
Yes
No
For students from Jordan: Please evaluate your English ability.
Spoken:
Excellent
Good
Satisfactory
Poor
Listening / Understanding:
Excellent
Good
Satisfactory
Poor
Reading:
Excellent
Good
Satisfactory
Poor
Written:
Excellent
Good
Satisfactory
Poor
Family Information
Father's first and last name:
Mother's first and last name:
Names and ages of brothers and sisters:
Family email address if applicable:
Language spoken at home:
School Information
Name of school you attend:
School mailing address:
School telephone number:
Grade you are attending:
9
10
11
12
Do you have Internet access at your school?:
Yes
No
Person at your school who will verify your academic standing:
Letter of Academic Standing from this person must be completed and returned in order for your application to be complete. Please print out this form and give it to your school representative for completion.
Technical Assessment
In a brief essay (8-10 sentences), please describe how you think technology and media can benefit development in your community:
Please indicate which of the listed computer programs you have used and your skill level. Please answer honestly. We do not expect participants to have all of these skills prior to this program.
What type of computer do you use?:
MacIntosh
IBM compatible
Do you own this computer?:
Yes
No
How often can you use this computer?:
daily
once a week
2-3 times a week
once a month
other
My computer experience and skills
I am able to
1. Use email:
No
If yes, select level:
Basic
Intermediate
Advanced
2. Use online forums:
No
If yes, select level:
Basic
Intermediate
Advanced
3. Conduct Internet searches:
No
If yes, select level:
Basic
Intermediate
Advanced
4. Use chats/Instant Messaging:
No
If yes, select level:
Basic
Intermediate
Advanced
5. Use Office Suite products such as Word, Excel and Access:
No
If yes, select level:
Basic
Intermediate
Advanced
6. Scan and make basic alterations to an image:
No
If yes, select level:
Basic
Intermediate
Advanced
7. Use image editing applications such as Adobe Photoshop, CorelDraw, Macromedia, etc.:
No
If yes, select level:
Basic
Intermediate
Advanced
8. Create PowerPoint presentations:
No
If yes, select level:
Basic
Intermediate
Advanced
9. Create animation within a presentation:
No
If yes, select level:
Basic
Intermediate
Advanced
10. Use and download images from a digital camera:
No
If yes, select level:
Basic
Intermediate
Advanced
11. Create templates for presentation applications:
No
If yes, select level:
Basic
Intermediate
Advanced
12. Create and edit digital videos, with programs such as Premiere, iMovie, Final Cut Pro:
No
If yes, select level:
Basic
Intermediate
Advanced
13. Create a basic web page:
No
If yes, select level:
Basic
Intermediate
Advanced
14. Use HTML code:
No
If yes, select level:
Basic
Intermediate
Advanced
15. Use an HTML editor such as DreamWeaver, FrontPage, etc.:
No
If yes, select level:
Basic
Intermediate
Advanced
16. Access and use a DVD player:
No
If yes, select level:
Basic
Intermediate
Advanced
Interests/Activities
Please describe your interests and any extra-curricular activities you are involved in at school:
Please describe any community-service projects in which you are involved:
Project Selection
All MEDIA Program participants are required to identify an issue/problem that is of concern in their community which they feel passionate about. Prior to and during the exchange components of this program, students will use new media and technology skills to create digital video stories for presentations in their communities. Please select a topic below that you would like to research. You may select a topic not on the list, but you must be able to describe why it is relevant and how you will conduct research on it.
Substance abuse prevention:
Hunger:
Environmental issues:
After school student activities:
Youth and media:
Democracy education:
Youth clubs:
Women's Rights:
Conflict Resolution:
Media Ownership:
Media Violence:
Advertising's influence on youth:
Other:
Describe why this issue is important and interesting to you. Describe why you are passionate about this topic.
Mentor Information
We would like you to identify an adult in your community who will serve as your mentor for the MEDIA Program. Your mentor will be asked to meet with you and provide support to you during all program components. Please refer to the Expectations for Mentors page for more information on what your mentor will be asked to do. Your mentor can be a teacher, community leader, neighbor, etc. Please make sure you talk with your mentor before you send us his/her name.
Your mentor's first and last name:
Relationship to mentor (for example, a teacher, neighbor, counselor, librarian, etc.):
Mentor's email address:
Mentor's mailing address (street, pob, city, state, zip code):
Mentor's telephone number (please include the area code/country/city codes):
Mentor's cell phone number:
Above you have chosen a mentor for this workshop. Please describe in 6-8 sentences why you selected this individual and how you feel he/she will be able to best support you in implementing your community project.
Essay Questions
1. Youth are being bombarded with media messages on a daily basis all over the world. What is it about media education and this program that interests you the most and why? Please be as specific as you can.
2. Throughout the MEDIA program, you will be required to work closely with young people from abroad. What qualities do you have that would make you a good candidate for this program and what do you hope to gain from the intercultural experience? Please be as specific as you can.
3. What role do you feel that youth leaders currently have in your school? In what ways do you think that young people could contribute more to your school and community? When have you taken on a leadership role? Please describe your experience and discuss the qualities of a good leader. Please be as specific as you can.
Submitting Application
Once you have completed the application, please hit the "Send" button below. You will be given a URL that will allow you to return and modify your application up until the deadline, January 1, 2006 . Please save this URL address, as you are the only one who will receive it!Renee Berrian / (802) 496-4545 in Vermont or Raghda Quandour / (079-5291-670) in Jordan.
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