U.S.

Department of State’s Kennedy- Recent Photo

Lugar Youth Exchange and Study (YES)
Gambar terbaru
Preliminary Application Form
Borang Permohonan

All forms must be HANDWRITTEN clearly in BLACK or BLUE ink pen and every question must be answered.
Setiap borang hendaklah ditulis dengan jelas sama ada dalam dakwat HITAM atau BIRU sahaja.Sila jawab semua soalan dengan lengkap.

CHECKLIST- SENARAI SEMAK

Check that you have filled ALL the information on this form and include:
Semak semula SETIAP maklumat yang telah diisi dan sertakan perkara-perkara yang berikut:

Your past 2 years’ school results (Compulsory)

Keputusan peperiksaan terkini bagi 2 tahun lalu (Wajib)

A photocopy of your IC (front and Back) (Compulsory)

Satu salinan kad pengenalan (depan& belakang) (Wajib)

A recent passport photograph of yourself (Compulsory)

Gambar ukuran passport yang terbaru. (Wajib)

PERSONAL INFORMATION - MAKLUMAT PERIBADI

Full name (as in IC) – Nama Penuh (seperti dalam K/P) Birthdate – Tarikh Lahir Gender – Jantina
(dd/mm/yy)
 Male (Lelaki)
House Phone Number - No Telefon Rumah: Mobile Number - Nombor Telefon Bimbit:  Female (Perempuan)

Home Address - Alamat Rumah Do you have a disability which is relevant to your application?
 Yes/Ya
 No/Tidak
If Yes, please give details:

Email Address- Alamat Emel Identification Card Number (IC No.) – Nombor Kad Pengenalan

KENNEDY-LUGAR YOUTH EXCHANGE AND STUDY PROGRAM

Kennedy-Lugar YES program Overview:
The U.S. Department of State established the Kennedy-Lugar Youth Exchange
and Study (YES) program in October 2002 in recognition of the importance of
youth exchange as a key component to build bridges between citizens of the
U.S. and countries around the world. The program is funded by the U.S.
Department of State and provides scholarships for high school students from
countries with significant Muslim populations to attend high school in the U.S.,
live with an American host family, and serve as “youth ambassadors” for their
home countries.
The YES program officially launched in Malaysia in 2004 to expand
communication between the people of United States and Malaysia to promote
mutual understanding and respect. Since then, more than 550 Malaysian
students have participated in the YES program and are now members of the
YES and U.S. Embassy Alumni communities. Malaysian YES students spend 6
months in the U.S. from January to June.
The U.S. State Department’s YES program is administered in partnership with a
consortium of non-profit organizations. In Malaysia, AFS Malaysia manages YES
in partnership with the U.S. Embassy Kuala Lumpur.
In keeping with the U.S. Government-sponsored initiatives dedicated to
democratic reform, the competition for the Youth Exchange and Study scholarship
is merit-based and open at no cost to all applicants who meet the following
requirements:
1. Be enrolled in Form 5 at the time of application (and
cannot be younger than 15 or older than 18.5 on
January 15, 2020); Students with disabilities are
encouraged to apply and they can be in Form 3, 4 or 5
at time of application (and cannot be younger than 15 or
older than 18.5 on January 15, 2020)
2. Have the equivalent of a B average or better;
3. Be a citizen of Malaysia.
4. Demonstrated leadership, community involvement in
extracurricular activities.
Note:
YES seeks to ensure diverse participation in the program, representing all of
Malaysian society.
Please submit only photocopies of the original document. AFS Malaysia will not be
held responsible for any loss or return of the documents to you.

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PRELIMINARY APPLICATION l KL YES PROGRAM
SCHOOL INFORMATION - MAKLUMAT SEKOLAH

Name of School- Nama Sekolah

School Address- Alamat Sekolah

Telephone Number- Nombor Telefon Fax Number- Nombor Fax

I am in Form (kindly provide class name) Type of School

Saya di tingkatan (sila catitkan nama kelas) Jenis Sekolah

 Residential School / Sekolah Berasrama Penuh

 Religious School / Sekolah Agama
Post held in school (if any)
Jawatan disandang di sekolah (jika ada)  Private School / Sekolah Swasta
 Special Education School / Sekolah Pendidikan Khas
 Daily School / Sekolah Harian:
o Sekolah Menengah Kebangsaan
o Sekolah Jenis Kebangsaan Cina
o Sekolah Jenis Kebangsaan India
o Lain-lain: __________________

PARENTS/GUARDIAN(S) INFORMATION- MAKLUMAT IBUBAPA/PENJAGA

What is your family structure? / Apakah status ibu bapa anda?

Parents are: / Ibu bapa saya:
married separated single parent divorced
berkahwin tinggal berasingan Ibu bapa tunggal berpisah

Information about the people with whom I live / Maklumat ibu/bapa yang saya tinggal bersama:

I live with: both my father and my mother my mother my father stepmother stepfather
Saya tinggal bersama: Kedua ibu bapa saya ibu sahaja bapa sahaja ibu tiri bapa tiri

my guardian(s), indicate your relationship to your guardian(s),

penjaga, hubungan saya dengan penjaga ialah

Father/Stepfather/Guardian Name- Nama Bapa/Bapa Tiri/Penjaga

Employer- Majikan Occupation-Pekerjaan

Office Number- Nombor Pejabat Mobile Number-Nombor Telefon Bimbit

Email Address- Alamat Emel

Mother/Stepmother/Guardian Name- Nama Ibu/Ibu Tiri/Penjaga

Employer- Majikan Occupation-Pekerjaan

Office Number- Nombor Pejabat Mobile Number-Nombor Telefon Bimbit

Email Address- Alamat Emel

EMERGENCY CONTACT- MAKLUMAT KECEMASAN

If your parents/guardian cannot be reached, please indicate someone in your community whom we can contact:
Jika ibubapa/penjaga tidak dapat dihubungi,sila nyatakan maklumat individu yang boleh dihubungi:
Full Name-Nama Penuh Relationship-Hubungan

Office Phone-Telefon Pejabat House Phone-Telephone Rumah Mobile Number- Telefon Bimbit
PERSONAL STATEMENT- PENGENALAN DIRI

• Describe yourself and your personality and what is important to you.

Huraikan mengenai diri dan personality anda dan apa yang penting dalam hidup anda.
• Detail your participation in school and community activities.
Perincikan penyertaan anda di sekolah dan aktiviti-aktiviti kemasyarakatan
• What motivated you to apply and what do you hope to gain from the YES program?
Apakah yang menjadi motivasi anda untuk memohon dan apa yang anda berharap untuk peroleh dari program YES?

Tips/Tip:
1. Tell us about yourself: Introduce yourself, your personality, your relationship with your family and friends, your responsibilities at homes/school. List your favorites,
interests or hobbies, etc./ Beritahu kami tentang diri sendiri: Perkenalkan diri anda, personaliti anda, hubungan anda dengan keluarga dan rakan-rakan anda ,
tanggungjawab anda di rumah / sekolah , senaraikan kegemaran kami, minat atau hobi
2. Tell us about your expectation (before, during, and after) the exchange program. / Sila nyatakan harapan anda (sebelum, semasa & selepas) program pertukaran
3. Tell us about your goals/plans which are important to you; and why you think you should be chosen for the YES program. / Sila nyatakan tentang matlamat / pelan
yang penting kepada anda; dan mengapa anda fikir anda perlu dipilih untuk Program YES?

* Your entire personal statement should be between 150-300 words ONLY. Please write in English.
Kenyataan diri anda haruslah di antara 150- 300 patah perkataan SAHAJA. Sila tulis didalam Bahasa Inggeris.

** If the space provided is insufficient, you may include an attachment.

Jika ruang yang disediakan tidak mencukupi, anda boleh menggunakan kertas tambahan.

LANGUAGE BACKGROUND – LATAR BELAKANG BAHASA

What is the primary language spoken in your home? / Apakah bahasa pertuturan anda di rumah?

OTHER INFORMATION- MAKLUMAT LAIN

How did you hear about the YES program? - Bagaimanakah anda mengetahui mengenai program YES?

 Online/Internet  School/Sekolah  Road Show/ Promosi Bergerak

 Friends / Kawan  Newspaper / Surat Khabar  Others / Lain-Lain
 ETA (English Teaching
Assistant)

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PRELIMINARY APPLICATION l KL YES PROGRAM
Have any of your family members participated on the YES, AFS, or any other exchange program?
Adakah sesiapa dari ahli keluarga pernah menyertai program YES, AFS atau program pertukaran lain?

 No/Tidak  Yes, please specify relationship, name and which year? Ya.Sila nyatakan nama,negara dan tahun penyertaan

Are you or any of your family members involved in AFS?

 No/ Tidak  Yes. If yes,how?/ Ya.Jika ya, bagaimana?

Do you have any volunteer experience? If yes, please list your volunteer activities.
Sila nyatakan sekiranya ada pengalaman sukarelawan di sini.

DECLARATION - AKU JANJI

I have discussed my application with my family and wish to apply for participation in the Kennedy-Lugar Youth Exchange and Study program.
Saya telah berbincang dengan keluarga saya mengenai permohonan ini dan ingin memohon untuk menyertai program Kennedy-Lugar Youth Exchange and Study

Applicant’s Signature / Tandatangan Pemohon Parent/Guardian’s Signature / Tandatangan Ibu/Bapa/Penjaga

Date/Tarikh: Date/Tarikh:

SUBMISSION POLICY
Send this completed application form on or before 30 th April 2019 to:
Hantarkan borang permohonan yang telah dilengkapkan sebelum 30 hb April 2019 kepada:

Yayasan AFS Antarabudaya Malaysia

A-10-2, Block A, Plaza Glomac
Jalan SS 7/19, Kelana Jaya,
47301 Petaling Jaya
Selangor, Malaysia
yesprogram.malaysia@afs.org

Application Deadline: 30 April 2019

Notes:

1. Application can be submitted by post to the AFS office or online via email at yesprogram.malaysia@afs.org.
2. If you are sending by post, please submit only photocopies of the original document. AFS Malaysia will not be held responsible
for any loss or return of the documents to you.
3. Kindly attach all required documents with your completed forms if you submit via email.
4. For any inquiries and concerns about the YES Program application, please email to yesprogram.malaysia@afs.org with the Subject Heading:
YES 2020 Inquiry

Please note that applying to the YES program does not automatically guarantee you a spot in the YES program. Your application will be
reviewed by the AFS Selection Committee to determine your eligibility to participate in the program.
Should any information disclosed be found not to be true, your application will be disqualified.

Adalah dimaklumkan bahawa permohonan ini tidak secara automatik melayakkan anda ke Program YES. Permohonan anda akan dikaji
semula oleh Jawatan Kuasa Pemilihan AFS untuk menentukan sama ada anda layak untuk mengikuti Program ini.
Sekiranya didapati sebarang maklumat yang diberi tidak benar, permohonan anda akan terbatal.

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PRELIMINARY APPLICATION l KL YES PROGRAM