The Bureau of Educational and Cultural Affairs

U.S. Department of State

through
Northern Illinois University (DeKalb, U.S.A.)
in partnership with
Filipino Institute for the Promotion of Integrity & Nobility (FILIPINO, Inc)

Philippine Youth Leadership Program

Batch 13 (2015-2016)

Theme:
“Environmental Leadership in the Philippines: Developing Youth as Agents of Change and Ecological Activism”

A one-year project that covers workshops and learning activities, including a four-week campus-
based study and exposure period in the U.S., focusing on responsible citizenship, community
service leadership and action plan development and implementation.

APPLICATION FORM: YOUTH PARTICIPANT

Please print legibly and do not leave any item unanswered. Applications with
incomplete entries or supporting documents and without parents’ or guardian’s
consent may be subject to disqualification.
Photo
Completed forms and required documents should be placed in a sealed envelope and Passport Size
sent to Dr. Lourdes Tolod, School of Education, Xavier University, Cagayan de Oro City.
Applicants should notify the PYLP Area Coordinator or Contact person as to the
transmission details. Deadline for submission: November 25, 2015. Date taken

PERSONAL INFORMATION: (To be eligible, you must be at least 15 years old and not more than
17 years old by April 2016.)

First Name (CAPITALS please): ___________________________________________________

Middle Name (CAPITALS please): __________________________________________________

Last Name (CAPITALS please): ____________________________________________________

Sex: □ Male □ Female Age: ________ Date of Birth: ________________________________

Birth Place: ____________________Religion: ______________ Ethnicity /Tribe: ____________

Home Address: __________________________________________________________________

_______________________________________________________________________________

Permanent Mobile#: __________________ Permanent Email Add: ________________________

Grade Level/Year & Course: ____________________________________________________________

Grade Average: __________________(For Junior High School, submit latest form 138 or 2nd
grading period records of school year 2015-2016; for First Year College: First Semester Grades SY 2015-2016).

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Please write down any special skills that you have:
____________________________ _______________________________
____________________________ _______________________________
____________________________ _______________________________

PASSPORT INFORMATION:

Do you currently hold a Philippine Passport? □ Yes □ No

Date of Issue: _____________ Valid Until ____________ Place of Issue: ____________________

PARENTS’ INFORMATION:

Father’s Name: __________________________________________________________________

(Family Name) (First Name) (Middle Name)

Birthday: _________________ Age: __________ Birthplace: ____________________________

Ethnicity: _________________ Religion: _____________ Occupation: ____________________

Mother’s Name: _________________________________________________________________

(Family Name) (First Name) (Middle Name)

Birthday: _________________ Age: __________ Birthplace: ____________________________

Ethnicity: _________________ Religion: _____________ Occupation: ____________________

Parents’ Address (if not the same as above): _______________________________________________

_______________________________________________________________________________

Father’s Permanent Mobile #: ______________ Mother’s Permanent Mobile # _______________

SCHOOL/INSTITUTION INFORMATION:

Name of school: _________________________________________________________________

Address: _______________________________________________________________________

Name of school head: _____________________________________________________________

Permanent Mobile #:_________________________ Email Add:___________________________

PARTICIPATION IN SCHOOL- and COMMUNITY-BASED ACTIVITIES:

Membership in school organizations and civic clubs at least as far back as two years to the present.
Please attach authenticated photocopies of proof of membership by the organizer or school adviser
and activity participation record.
______________________________________ ________________________________________

PYLP 13 Youth Application Form Page 2 of 5

______________________________________ ________________________________________
______________________________________ ________________________________________

Membership in other organizations or non-government organizations (NGOs) at least as far back

as two years to the present. Please attach authenticated photocopies of proof of membership by the
organizer or school adviser and activity participation record.)
______________________________________ ________________________________________
______________________________________ ________________________________________
______________________________________ ________________________________________

Titles and dates of other workshops participated in related to peace-building, leadership and
environment at least as far back as two years till the present. Please attach authenticated
photocopies of certificates of attendance or participation by the organizer or school adviser:
______________________________________ ________________________________________
______________________________________ ________________________________________
______________________________________ ________________________________________

OTHER INFORMATION:

Do you have any immediate relative(s) or cousin(s) within the first degree of consanguinity who
are recipients of a study grant or have participated in a U.S. Department of State program?

If NO, proceed to REFERENCES; if YES, please answer the following:

Name: _________________________________________________________________________
(Family Name) (First Name) (Middle Name)

Relationship: ___________________ Name & Year of Program: __________________________

REFERENCES: (Kindly provide below two (2) names of disinterested persons who know you well as
character references.)

Name (1): ______________________________________________________________________

(Family Name) (First Name) (Middle Name)
Relationship: ________________________ Position: __________________________________
School/Organization: _____________________________________________________________
Permanent Mobile # _________________ Permanent Email Add: __________________________

Name (2): ______________________________________________________________________

(Family Name) (First Name) (Middle Name)
Relationship: ________________________ Position: __________________________________
School/Organization: _____________________________________________________________
Permanent Mobile # _________________ Permanent Email Add: __________________________

OTHER REQUIREMENTS:

1. Two essays: (a) Please write something about yourself in a short essay of not more than 1,000 words.
(b) On another sheet, please share with us your perceptions on critical needs and issues confronting
your community and the related possible projects that would help improve and develop your local
community. These two essays should be attached to the application form.

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2. Documents(All documents should be authenticated by concerned organization/institution)
a) Scanned or photocopy of birth certificate issued by the National Statistics Office/NSO
b) Scanned or photocopy of high school report card or first semester grades in college
c) Scanned or photocopy of Certifications of Good Moral Character
d) Scanned or photocopy of Certificates of Membership in organizations
e) Scanned or photocopy of Certificates of Participation in seminars/workshops
f) Scanned and original copy of endorsement of your application by your school
g) Scanned or photocopy of parents’ marriage certificate or CENOMAR (if applicable)
h) Scanned or photocopy of parents’ birth certificates
i) Completed Application Form with signed Certification and Consent (at the bottom of this
form).
j) Signed and notarized Affidavit of Consent and Certificate of Undertaking by parents or
guardian (draft attached).

CERTIFICATION AND CONSENT

I hereby certify that I have read and understood all sections of this form and that all facts
and information placed herein are true and correct to the best of my knowledge. I further declare
that any information given by me that may be untrue will be grounds for disqualification to the
program.

Further, I subscribe and agree that the PYLP Selection Committee has the sole prerogative
to select and nominate the delegates, and its decision is final and executory. If selected as a
participant, I commit to participate actively in all the activities of the program.

______________________________________ Date: _______________

(Signature over printed name of applicant)

With our Conformity:

________________________________________ _______________________________________
(Father’s/Guardian’s Signature over Printed Name) (Mother’s/Guardian’s Signature over Printed Name)
Date: ______________________ Date: ________________________

When submitting applications, please ensure completeness of information and requirements

specified. Applications may be received by any of the following coordinators and/or contact
persons:

South Cotabato
Al Quillope
Email: earthworm_afq@yahoo.com / Phone #: (0921) 560 0702
Notre Dame of Marbel University, Koronadal City, South Cotabato

General Santos City and Sarangani Province

Allan Remedios
Email:onjie123@gmail.com / Phone # (0998) 860 9030
Holy Trinity College, Gen. Santos City
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Cotabato City and Maguindanao Province
Dr Alfred Born Taboada
Email: alfredborntab@gmail.com / Phone # (0918) 579 5835
Address: Dean, STI College, Dorotheo St., Cotabato City

Misamis Oriental, Lanao del Norte, Lanao del Sur, Bukidnon, Caraga Region
Mona Lisa Pangan
Email: monliz_75@yahoo.com / Phone #: (0906) 441 1509
Campus Ministries Office, Xavier University, Cagayan de Oro City 9000

Jana Jean Dacobor

Email: janjayn@yahoo.com/ Phone #: (0917) 716 9023
Door 2 Silatan Apt. Zone 3, Bagong Silang Highway
9200Iligan City

Zamboanga City, Zamboanga del Norte, Zamboanga Sibugay, Sulu, Tawi-Tawi and Basilan

Cecille Ancheta La Plana

Email: cecillelaplana@gmail.com / Phone #: (0927) 57819142
Purok Orchids, Tirso Babiera Dr., African Daisy St.
Poblacion, Ipil, Zamboanga Sibugay 7001
Zamboanga del Sur
Mohamad Ali Esmael Ramber
Email: moal_ramber@yahoo.com/ Phone # 0916-7341661
Purok Sunshine, Alano St., Santiago, Pagadian City

Coordinating Center:
Dr Lourdes Tolod
Email: ltolod@yahoo.com / Phone #: (0917) 716 9292
School of Education, Xavier University
Cagayan de Oro City 9000

Notes:

1. Shortlisted Applicants will be directly notified as to date and location of the final interview.

2. Applicants who have family members (father, mother, sister or brother) and cousins within
the first degree of consanguinity who have participated in any US Department of State
sponsored grants may be subject to disqualification.

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