Southeast Asia

Youth Leadership Program

Participant Information Sheet
This information will be used to place you with an appropriate host family and
to inform program staff of important issues.
Please answer the questions as truthfully and completely as possible.

This information will be kept confidential and will not be shared with other program participants

1 Last Name : Butar-butar

2 First Name : Anggelica
3 Middle Name : Kristanti Br Gender : Female
4 Country : Indonesia Birth Date : January 6​th ​2000
5 Email Address: anggelbutarbutar @gmail .com

6 How often do you check your email?

○​ Several times a day ​○​ Once a day Less than once a day
Yes No
7 Do you have any siblings (brothers and sisters)?
✓ •
1. Jhontera Parlindungan Butar-butar ( 24​th
)
2. Nicolas Butar-butar ( 20​th ​)

8 If yes, what are their names and ages? 3. -

4. -

5. -
Parents
-
-
Who lives in your household (parents, -
9
siblings, extended family, staff)? -
-
-
-
No
Yes
10 Do you have a part-time job? ✓
•

11 If yes, what is it?

 How often do you perform chores (wash dishes, sweep floors, babysit, take out the garbage,
etc.) or help out around the house?
o Often
✓ Sometimes
o Rarely
o Never
1. Sweep the floors
If you do help out, which chores do you like to
13 2. Wash dishes
do?
3. cook somefood.

Many Americans have pets, usually dogs and cats. Please indicate whether would be
14
comfortable living in the following situations (choose all that apply to you):

o The dogs have free roam of the house

o The dogs are in the house, but kept out of my bedroom
o The dogs are kept in a specific room of the house when allowed inside
o The dogs are kept outside
o There are no dogs on my host family’s property
✓ Cats are kept in the house
Yes No
15 Do you smoke?
• ✓
Please note: In the United States, persons under 18 are prohibited from purchasing tobacco products, and smoking
generally prohibited indoors.
How would you like to observe your religion while you are in the United States? We will do our
16
best to accommodate your wishes.

o I do not want to observe a religion while in the United States (go to question 18)

o I want to practice my religion in the United States (choose one option below)
o I am curious to see religious services of my faith in the United States
o I would like the opportunity to pray or attend services of my religion regularly
✓ It is very important to me to have the opportunity to pray or attend services regularly
17 Please specify which religious services you would like to attend:
I’m a Protestant Christian . My church is The Nusantara Evangelical Reformed Church ( GPIN )

If your host family attends religious services, they will invite you to join
Yes
18 them. This would be a good cultural exchange opportunity. Are you No
•
interested in doing this if the opportunity arises? ✓

19 Yes No
Do you have any allergies?
✓ ​•
1. Dust
If you have allergies, what are you allergic to?
20 2. -
(For example: pollen, shellfish, peanuts, cats, dust)
 3. -
Allergy Treatment
Please list any treatment for allergies, if 1. Dust Using mask
21 applicable (please use additional space if
needed). 2. -

No Goat’s meat
List your dietary restrictions or preferences, if
any. ​(For example: vegetarian, no pork, kosher, No cat’s meat
22
halal, no shellfish.)​ We will try our best to
accommodate you.

-
Do you have any physical limitations we should
23 be aware of (example: hard of hearing)? Please
list any.
-
Do you have any medical conditions we should
24 know about (example: Diabetes, Asthma)?
Please list them, plus any relevant information.
1. -
2. -
Please list any medications you take and
25 3. -
dosages (please use additional space if needed)
4. -
5. -
Do you use social networking sites such as Yes No
26
Facebook or Twitter? ✓ •

27 What social media site(s) do you use regularly? Facebook

Yes No
28 Do you have access to high speed internet? ✓ •

If yes, where (example: at home, at an internet café,

29 At home
at school)?

Is there anything else you would like us to know

30 about you that has not been addressed elsewhere
during the application process?
 Is there anything else you would like us to know
31 about you that has not been addressed elsewhere
during the application process?