Application Form
St. Joan of Arc Catholic High School
Tanzania Leadership Program 2015-16
1) Personal Information:
Name: ___________________________________
Birth date: ____________________
Address: ___________________________ City: _____________ Postal Code:_________
Phone #1: _________________________ Health Card #: ________________________
Phone #2: _________________________
Email (student): _______________________
Passport #: ________________________
Email (parent): ________________________
2) Health and Safety: To derive maximum benefit from this program it would be in the
best interest of each participant to be in good health and proper fitness.
a) Are you willing to commit yourself to a pre-trip fitness program? _____
b) Are there any health issues that you would like to discuss with the directors
relative to your participation in this program? _____
c) Are you willing to commit to a Code of Behaviour? _____
3) Community: The mutual support and co-operation between participants will be vitally
necessary in dealing with the challenges presented in this experience. What strengths will
you be able to contribute to the group?
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4) Service: Service to others is a very meaningful component of our programs.
a) Could you identify any volunteer activities in which you have been involved?
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b) For one of these activities, describe how it benefits others:
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c) Its value to you:
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5) Conditions: Adapting to the travel, climate, and culture in this part of the world may be
difficult.
a) What will be your greatest challenge?
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b) How will you prepare for it?
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6) Education:
a) What program are you currently studying in school ie. Academic or Applied?
_________________________________________________________________________
b) What level (year) are you currently enrolled in? ________________________________
c) What are your future educational goals?
___________________________________________________________________
7) Motivation: This experience has the potential for extraordinary learning, growth, and
personal fulfillment.
a) In one paragraph describe what attracts you to this program.
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c) In one paragraph describe what you hope to gain from this program.
_________________________________________________________________________
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8) Teacher Referral and Parent Consent: These (2) forms are attached.
9) Passport: Upon acceptance to the program a photocopy of participant passports will be
required.
10) Meetings/Interviews: There will be a parent/student information meeting held at
St. Joan of Arc Catholic High School on Wednesday, May 28th, 2015 at 6:00pm.
Applications are due Thursday, June 4th, 2015 to the Guidance Office at 12:00 noon.
Each applicant will be invited to an interview with the Principal and Teachers to assess
his/her suitability for the program. This is intended to give each applicant the opportunity
to determine the appropriateness of the program for their purpose. Interviews will take
place Monday, June 8th and Tuesday, June 9th, 2015. Once we have successfully
completed the interview process, a $500 deposit is due to the Main Office on Monday
June 16th, 2015. Cheques will be made payable to St. Joan of Arc Catholic High School.
Applications: Completed applications should be submitted by Thursday, June 4th, 2015
at 12 noon.
To: Guidance Office
St. Joan of Arc High School
460 Mapleton Ave
Barrie, ON
L4N 9C2
Phone: 705-721-0398
St. Joan of Arc Catholic High School
460 Mapleton Avenue
Barrie, ON L4N 9C2
Tel: (705) 721-0398 Fax: (705) 721-1438
Simcoe Muskoka Catholic District School Board
Mr. J. Timmins-Principal
Mrs. M. Boucher-Vice Principal___Mr. S._Charlebois-Vice Principal______________
“The dedication and courage of St. Joan of Arc is our inspiration in providing excellence in
Catholic education and fostering the development of minds, bodies and spirits”
Tanzania Project Application - Parent Consent
The purpose of this letter is to grant_________________________ permission
(Student Name)
to participate in the application process for selection of the JOA-Tanzania
2015-2016 Project.
I _____________________________will be attending the mandatory parent
(Parent/guardian)
information night which will be held on Thursday, May 28
at St. Joan of Arc Catholic High School.
th
2015 at 6:00pm
Following the parent information night, the applications will be due on
Thursday, June 4th, 2015 to the JOA Guidance Office at 12 noon. The
applications will be reviewed, and candidates will be interviewed on June 8th
and June 9th, 2015. Those selected will be informed in mid June 2015 and will
be required to attend an information meeting in September (time and date
TBA).
PARENT(S)/GUARDIAN(S) SIGNATURE:___________________________________
Teacher Referral Form - St. Joan of Arc Catholic High School
Tanzania Leadership Program 2015-2016
(This form can be submitted directly to the Guidance Office)
Student Name: _________________________________ Teacher Name: ______________________________________________
How long have you known this student? __________________________________________________________________________
In what capacity have you worked with this student? Describe________________________________________________________
____________________________________________________________________________________________________________
Rank this student according to the criteria listed below by circling the appropriate number on the scale provided.
CRITERIA
Not Yet
Demonstrated
Average
Exceptional
Motivation
0
1
2
3
4
5
6
7
8
9
10
In School
Community
Involvement
Outside
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
Initiative
0
1
2
3
4
5
6
7
8
9
10
Academics
0
1
2
3
4
5
6
7
8
9
10
Adaptability
0
1
2
3
4
5
6
7
8
9
10
Ability to work
With Others
0
1
2
3
4
5
6
7
8
9
10
Ability to accept
Changes
0
1
2
3
4
5
6
7
8
9
10
Leadership
0
1
2
3
4
5
6
7
8
9
10
Positive Attitude
0
1
2
3
4
5
6
7
8
9
10
Ability to
Communicate
0
1
2
3
4
5
6
7
8
9
10
Compassion
0
1
2
3
4
5
6
7
8
9
10
Acceptance of
0
Differences in Others
1
2
3
4
5
6
7
8
9
10
Have you ever had and/or observed a situation with this student that you feel may contribute to/detract from his/her ability to be
a successful participant in the Tanzania Leadership Program? Briefly describe.
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Rate your overall recommendation of this student by placing an “X” in the appropriate place on the following scale”
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Not
Recommend
Strongly
Recommend
with some reservations
Recommend
On the back of this sheet, please comment in writing, on any of the above criteria and/or on any additional information that you
have that will assist in the selection committee.
________________________________________________
Teachers Signature
Additional information I would like to add about this applicant:
____________________________
Date
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