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I. PERSONAL INFORMATION

This information is for your visa. Use the details from your international passport.

Country of your interview:

First Name:

Middle Name:

Last Name:

Other Names:

Gender:

Male

Female

Date of Birth:

City of Birth:

Country of Birth:

Country of Citizenship:

Country of Legal Permanent Residence:

Street/Apartment:

Town/City:

Post/City Code:

Country:

Phone Number:

Mobile Number:

Email:

Height (ft/in):

Weight (lbs):

Marriage Status:

Married

Unmarried

Driver License:

Yes

Smoker:

Yes

II. EDUCATION

Are you currently a full-time student?:

Yes

Will you be a full-time student in October 2012?:

Yes

If Yes		List year of study:
		Name of College:
		Length of course/study years:
		Name of Faculty:
		Department:
		Others:

III. EMPLOYMENT

Are you employed in your home country?:

Yes

If Yes

Full-time

Part-time

Voluntary

Current employment:

If No

Previous employment:

Note: If you are not employed full-time or a full-time student you must provide evidence of reason to return in order to apply for the J-1 visa.

Preference for a specific U.S. employer (only to be completed by those without a verifiable job offer at time of application - SWT Self-Arranged Job Option only):

Company name:

Hiring manager's name:

Phone:

Fax:

E-mail:

Have you participated in an exchange programme in the past?:

Yes

If Yes		Agency/sponsor:
		Year(s):
		Recent employer in the U.S.:
		Contact name:
		Phone:

IV. SKILLS - COUNSELLOR APPLICANTS ONLY

Complete this section ONLY if you are applying for a Specialized Camp Counsellor position.

Please complete the following chart, indicating your highest level of camp activity qualification and experience:

My best camp activities and/or skills are:

I am certified to teach or coach:

Year of certification

I could teach or coach:

I could assist:

Copy of award enclosed?

Yes

(Note: The inclusion of any sport/activity in this list doeas not imply that you will be hired to teach/coach that activity on camp. However, if you do hold a teaching or coaching qualification that is internationally recognized, you should contact your Camp Director to discuss your position responsibilities and if you are eligible to receive the Qualified Status Bonus of up to $500).

Please detail your experiences in the skills listed above (When and where you gained your experience and the ages of people taught/coached):

Please provide details (including dates) of your experience with children (e.g. youth clubs, community programmes, play schemes, etc.) and include any leadership roles and ages of children you have worked with:

With which age group do you have the most experience?:

under 5yrs

6-10yrs

11-14yrs

15+yrs

Please list any unique skills you may have (cirkus skills, story-telling, face painting, etc.):

Do you have a swimming, life-guard or life-saving award?:

Yes

If yes, please list below any awards that were gained after the age of 16:

Certificate/Award

Date Issued

Expiry Date

Level/Grade

Copy Enclosed?

Yes

Note: To be considered for a waterfront position, certificates/awards must be current and you must have provide proof of certification prior to arriving at your camp.

If you are applying for a Special Needs Counsellor position, please complete the section below in addition to the section above:

Do you have experience working with people with disabilities?:

Yes

Would you consider working at a camp for mentally and/or physically challenged adults and or teenagers?:

Yes

WE works with selected high-quality Special Needs camps. There is a large demand for staff at these camps and whilst some camps require previous experience, others will determine your suitability from the information you supply and possibly an additional interview. As a special needs counsellor, your duties would include caring for the guest's personal (children and/or adults) needs (feeding, bathing and toileting), in addition to assistance with sports and other camp activities. If you are willing to work on a Special Needs camp, please use the space below to tell us why you would be suited to such work, detailing any previous experience working specifically with people with special needs. (Note: WE will not place you on a Special Needs camp without your consent.)

V. SKILLS - SWT AND CAMP SUPPORT APPLICANTS ONLY

Complete this section ONLY if you are applying for a Summer Work Travel or Camp Support Staff position.

Please tick the position below in which you have experience (E) and those in which you are willing (W) to work.

Cook

Guest Services

Assistant Cook

Cash Handling

Food Preparation

Secretarial/Office

Waiter/Waitress

Security

Dishwashing

Auto Mechanics

Maintenance

Driver

Painting

Theme Park Worker

Landscaping

Children's Host

Cabin/Room Cleaning

Shop Assistant

Janitorial

Pool Cleaner

Laundry

Life Guard

Reception Duties

Other

Adaptability and flexibility are important qualities employers seek. Are you willing to work in any area?:

Yes

If No, in which areas are you not willing to work?:

Please list previous employment below, starting with your most recent job:

Type of employment (part/full-time, paid/unpaid)

Dates of employment

Position/job title

Main activities and/or duties

Reference Enclosed?

Yes

Note: All SWT and Support Staff applicants must have previous full or part-time work experience, either paid or voluntary. Employment must have lasted for more than two weeks.

Do you have a swimming, life-guard or life-saving award?:

Yes

If yes, please list below any awards that were gained after the age of 16:

Certificate/Award

Date Issued

Expiry Date

Level/Grade

Copy Enclosed?

Yes

Note: To be considered for a waterfront position, certificates/awards must be current and you must have provide proof of certification prior to arriving at your job.

Please use the space below to describe your experience in those areas ticked above that you feel you are most qualified. Indicate any relevant duties performed and why you feel these particular areas are strongest.

Employers seek staff that have an adaptable, flexible and enthusiastic attitude toward the prospect of joining their teams. Using the space below, describe what you feel to be your strongest qualities in a work environment.

Please list any additional skills or experience you have.

VI. FAMILY BACKGROUND

This will improve your chances of the US Embassy granting your visa.

Can you show strong economic/social ties to your country?:

Yes

Please explain:

Do you have relatives/friends in the U.S.?:

Yes

If Yes, provide details:		Name:
		Relationship:
		Address:
		Phone:

Please describe your family background (number of members in your family background (number of members in your family, etc.) and any special interests you may have:

Have you ever traveled outside your own country?:

Yes

If Yes:		State countries visited, reason and length of stay:

VII. SPECIAL PLACEMENT REQUIREMENTS

Whilst we will try to accommodate your requests, no guarantee is given.

Do you have a friend/partner also making an application to WE with whom you would like to be placed?:

Yes

If Yes, provide details:		First name:
		Last name:
		Country:
		WE ID (if known):

If WE is unable to place you together, would you still like to be considered for placement?:

Yes

Please provide details of any special assistance you may required during placement (e.g. disabilities, special eating requirements):

By coming to the U.S. you will be exposed to new situations such as homesickness, curfews, restrictions on drinking and smoking, and strict adherence to rules and regulations. How do you feel you would react to these situations?:

VIII. MEDICAL INFORMATION

All participants are required to be in good physical/mental health and undergo a physical examination before departure to the U.S. A copy of the medical report validated by the doctor must be provided.

Please indicate below if you suffer or have ever suffered from any of the following conditions:
(Note: If you answer YES to any of these questions, you may need to obtain additional insurance, as WE insurance does not cover pre-existing conditions.)

Yes

Allergies to food

Epilepsy

Allergies to medicine

Dietary restrictions

Allergies to insect bites

Eating disorder

Other Allergies

Mental illness/breakdown

Physical disability

Depression

Diabetes

Other

Have you ever been the victim of sexual abuse?:

Yes

If you answered yes to any of the above questions or if there is any other important medical information that WE should be aware of that was not indicated above, please comment:

IX. CONFIDENTIAL BACKGROUND CHECK

WE requires that you obtain a police report and complete the following questions:

		Yes	No
Have you ever been the subject of:	a Caution of Bound over Order?
Have you ever been the subject of:	an arrest?
Have you ever been convicted of any:	violent offence/crime?
	drug/related offence/crime?
	sexual offence/crime?
Are you awaiting notification of any:	court judgment?
Are you awaiting notification of any:	police action against you?
Do you object to WE conducting a background check on you?

Note: If you answered Yes to any of the above questions, you must provide details including dates and judgments. Attach an additional sheet of paper.

The background check for UK APPLICANTS ONLY, is regarding your suitability for working with children. You are advised that under the provisions of the Rehabilitation of Offenders Act 1974 (Exceptions) order 1975, as amended by the Rehabilitations of Offenders Act 1974 (Exceptions) (Amendments) Order 1986, you should declare all convictions including "spent" convictions. Data Protection Act-You should be aware that your personal details will be stored in electronic format.

# - mandatory fields

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