Preliminary Application Form NH2018 Borang Permohonan NH2018
All forms must be HANDWRITTEN clearly in BLACK or BLUE ink pen and every question must be answered.
Setiap borang hendaklah ditulis dengan jelas menggunakan dakwat HITAM atau BIRU sahaja. Sila jawab semua soalan dengan lengkap.
Check that you have filled ALL the information on this form and include:
Semak semula SETIAP maklumat yang telah diisi dan sertakan lampiran yang berikut:
RM30 cheque/postal order/money order No._________ made payable to 'Yayasan AFS Antarabudaya Malaysia' (Compulsory) RM30 dalam bentuk cek/wang pos/kiriman wang No. __________ atas nama ‘Yayasan AFS Antarabudaya Malaysia’ (Wajib)
Your past 2 years’ school results (Compulsory)
Keputusan peperiksaan terkini bagi 2 tahun lalu (Wajib)
A photocopy of your IC (both side) (Compulsory)
Satu salinan kad pengenalan (kedua-dua belah) (Wajib)
A recent passport photograph of yourself (Compulsory) Gambar ukuran passport yang terbaru (Wajib)
Note: Please submit only photocopy of original documents (IC, school results, and certificates). AFS Malaysia will not be responsible in sending back original copies.
Peringatan: Sila hantarkan salinan dokumen asal sahaja (K/P, Keputusan peperiksaan terkini, dan sijil-sijil). AFS Malaysia tidak akan bertanggungjawab dalam memulangkan dokumen asal anda.
To find out which country/destination is the right fit for you, please refer to page 7.
Bagi destinasi program AFS yang sesuai dengan anda, sila rujuk muka surat 7.
If you require assistance with your preliminary application, or have any questions about our programs, please email our ‘Sending Team’ at info- mas@afs.org or call us at 03 7887 6866. Please note that our office hour is Monday – Friday (9am-5pm).
Jika anda memerlukan bantuan berkenaan permohonan anda, atau memerlukan maklumat lanjut tentang program kami, sila emel ‘Sending Team’ kami di info-mas@afs.org atau hubungi kami di talian 03 7887 6866. Pejabat kami beroperasi pada hari Isnin hingga Jumaat (9 Pagi- 5 Petang).
Full name (as in IC) – Nama Penuh (seperti dalam K/P) Birth date – Tarikh Lahir (dd/mm/yy)
Gender- Jantina
Male (Lelaki)
Female (Perempuan) Home Phone Number – No. Telefon Rumah: Mobile Number – No. Telefon Bimbit:
Home Address - Alamat Rumah: Do you have a disability?
Adakah anda mengalami sebarang kecacatan fizikal?
Yes/Ya
No/Tidak
If Yes, please give details: (Jika Ya, sila nyatakan:)
Email Address - Alamat Emel:
Recent Photo Gambar Terbaru
CHECKLIST- SENARAI SEMAK
PERSONAL INFORMATION – MAKLUMAT PERIBADI
Name of School- Nama Sekolah:
School Address- Alamat Sekolah:
Telephone Number- No. Telefon: Fax Number- No. Fax:
I am in Form (kindly provide class name):
Saya di tingkatan (sila nyatakan nama kelas):
Type of School (Please tick) Jenis Sekolah (Sila tandakan)
Residential / Asrama Penuh
Religious / Sekolah Agama
Private School / Sekolah Swasta
Special Education / Pendidikan Khas
Daily School / Sekolah Harian:
o Sekolah Menengah Kebangsaan o Sekolah Jenis Kebangsaan Cina o Sekolah Jenis Kebangsaan India o Lain-lain: __________________
Post held in school (if any):
Jawatan disandang di sekolah (jika ada):
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/Guardian: Divorced Deceased Separated Bapa/Penjaga: Bercerai Meninggal Berpisah Father/Stepfather/Guardian Name- Nama Bapa/Bapa Tiri/Penjaga:
Employer- Majikan: Occupation-Pekerjaan:
Office Number- No. Pejabat: Mobile Number-No. Telefon Bimbit: Email Address- Alamat Emel:
Mother/Guardian: Divorced Deceased Separated Ibu/Penjaga: Bercerai Meninggal Berpisah Mother/Stepmother/Guardian Name- Nama Ibu/Ibu Tiri/Penjaga:
Employer- Majikan: Occupation-Pekerjaan:
Office Number- No. Pejabat: Mobile Number-No. Telefon Bimbit: Email Address- Alamat Emel:
SCHOOL INFORMATION- MAKLUMAT SEKOLAH
PARENTS/GURDIAN(S) INFORMATION- MAKLUMAT IBU BAPA/ PENJAGA
Name-Nama Age-Umur Gender-Jantina School/Institution-Sekolah/Institusi
If your parents/guardian cannot be reached, please indicate someone in your community whom we can contact:
Jika ibu bapa/penjaga tidak dapat dihubungi,sila nyatakan maklumat individu yang boleh dihubungi:
Full Name-Nama Penuh: Relationship-Hubungan:
Office Phone-No.Telefon Pejabat: Home Phone- No.Telephone Rumah: Mobile Number- No. Telefon Bimbit:
What are the primary languages spoken in your home? / Apakah bahasa pertuturan anda di rumah?
Malay / Bahasa Melayu English / Bahasa Inggeris
Mandarin / Bahasa Mandarin
Tamil / Bahasa Tamil
Others / Lain-lain: _______________
What other languages do you know? Please indicate your speaking ability in each language. / Apakah bahasa pertuturan lain yang anda tahu?
Sila nyatakan kemahiran bertutur anda.
Language/
Bahasa:
Year of studies/
Tahun Pengajian:
Speaking abilities/
Kemahiran Bertutur:
Study at/
Belajar di:
Poor
Lemah
Fair
Sederhana Good
Bagus
Excellent
Amat Bagus
School
Sekolah
Extra Course
Kelas Tambahan
Poor
Lemah
Fair
Sederhana Good
Bagus
Excellent
Amat Bagus
School
Sekolah
Extra Course
Kelas Tambahan
Poor
Lemah
Fair
Sederhana
Good
Bagus
Excellent
Amat Bagus
School
Sekolah
Extra Course
Kelas Tambahan
Poor
Lemah
Fair
Sederhana Good
Bagus
Excellent
Amat Bagus
School
Sekolah
Extra Course
Kelas Tambahan
EMERGENCY CONTACT-MAKLUMAT KECEMASAN SIBLING(S) INFORMATION- MAKLUMAT ADIK-BERADIK
LANGUAGE BACKGROUND
1. Tell us about yourself: Introduce yourself, your personality, your relationship with your family and friends, your responsibilities at
home/school, list your favourites, interests or hobbies etc./ Perkenalkan diri anda, personaliti anda, hubungan anda dengan keluarga dan rakan-rakan, tanggungjawab di rumah / sekolah, senaraikan kegemaran, minat atau hobi anda.
2. Tell us about your expectation (before,during & after) the exchange program / Sila nyatakan harapan anda (sebelum, semasa & selepas) program pertukaran ini.
3. Tell us about your participation in school and community activities / Senaraikan penyertaan anda di sekolah dan aktiviti-aktiviti kemasyarakatan
4. Tell us about your goals/plans which are important to you; and why you think you should be chosen for the AFS Program? / Sila nyatakan matlamat / perancangan yang penting kepada anda; dan mengapa anda layak dipilih untuk Program AFS?
** Your personal statement should be between 100 -250 words ONLY / Kenyataan diri anda haruslah di antara 100-250 patah perkataan SAHAJA
PERSONAL STATEMENT – PENGENALAN DIRI
How did you hear about AFS? - Bagaimanakah anda tahu mengenai AFS?
Online/Atas Talian School/Sekolah Road Show/ Promosi Bergerak
Friends / Rakan Newspaper / Surat Khabar Others / Lain-Lain
__________________
Have any of your family members participated on an AFS program? Adakah sesiapa dari ahli keluarga anda yang pernah menyertai program AFS?
No/Tidak Yes, please specify student’s name, host country and which year? Ya.Sila nyatakan nama Pelajar, negara dan tahun penyertaan.
Are you or any of your family members involved in AFS? Adakah anda atau sesiapa dari ahli keluarga anda terlibat di dalam 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 disini sekiranya anda mempunyai sebarang pengalaman dalam aktiviti sukarelawan.
1. ______________________________________________________________ Year/Tahun: _________________
2. ______________________________________________________________ Year/Tahun: _________________
3. ______________________________________________________________ Year/Tahun: _________________
4. ______________________________________________________________ Year/Tahun: _________________
5. ______________________________________________________________ Year/Tahun: _________________
Are you willing to host an AFS participant?
Adakah anda sudi menjadi keluarga angkat kepada peserta AFS?
Yes / Ya
No / Tidak
Have you ever participated in any other exchange programs, travelled abroad or lived in another country?
(Please provide details; exchange program name, travel duration and country name) E.g.: UCC Summer Course in England in 2014 for two weeks (15 -29 November, 2014)
Adakah anda pernah menyertai mana-mana program pertukaran, melancong atau menetap di luar negara?
(Sila nyatakan nama program, tempoh dan nama negara)
Cth: UCC Summer Course di England pada tahun 2014 selama 2 minggu (15 -29 November, 2014)
No/ Tidak Yes. If yes, where and when, for what purpose? / Ya. Jika ya, dimana dan bila? Tujuan?
OTHER INFORMATION - MAKLUMAT LAIN
Please (√) select 5 to 10 activities of your interests below.
Sila (√) pilih 5 hingga 10 aktiviti kesukaan anda di bawah.
Individual Sports:
Hiking Mendaki
Horseback Riding Menunggang Kuda
Cycling Berbasikal
Sailing/Boating Berlayar
Camping Berkhemah
Canoeing Berkayak
Fishing Memancing
Yoga Yoga
Skateboarding Bermain Papan Luncur
Aerobics Aerobik
Hunting Memburu
Jogging Joging
Martial Arts
Seni Mempertahankan Diri
Organized Sports:
Hockey Hoki
Baseball Baseball
Basketball Bola jaring
Gymnastic Gimnastik
Softball Softball
Wrestling Gusti
Tennis
Tenis
Soccer Bola Sepak
Track & Field Aktiviti Padang
Diving/Swimming Menyelam/Berenang
Volleyball Bola Tampar
Golf Golf
Cross-country Running Merentas Desa
Art, Dance and Theatre:
Ballet Balet
Drawing/painting Melukis
Debate Debat
Photography Fotografi
Videography Videografi
Theatre/Drama Teater/Drama
Movie/Cinema Menonton wayang
Cultural Activities Aktiviti Kebudayaan
Crafts Kraf
Dance Tarian
Music:
Musical Instrument Alat Musik
Singing Menyanyi
Orchestra Orkestra
Concert Konsert
Listening to Music Mendengar Musik
Brass Band Pancaragam
Individual:
Board Games Mainan
Social Dancing Tarian Social
Collecting Mengumpul
Gardening Berkebun
Journalism Penulisan
Travel Melancong
Cooking Memasak
Reading Membaca
Watching Television Menonton Television
Computer Games Permainan Komputer
Community Activities:
Religion Services Khidmat Keagamaan
School Activities Aktiviti Sekolah
Scouts/Guides Pengakap
Volunteer Activity Aktiviti Sukarela
I HAVE DISCUSSED MY APPLICATION WITH MY FAMILY AND WISH TO APPLY FOR PARTICIPATION IN AN AFS PROGRAM SAYA TELAH BERBINCANG DENGAN KELUARGA SAYA MENGENAI PERMOHONAN INI DAN INGIN MEMOHON UNTUK MENYERTAI PROGRAM AFS
Applicant’s Signature / Tandatangan Pemohon Parent/Guardian’s Signature / Tandatangan Ibu/Bapa/Penjaga
Date/Tarikh: Date/Tarikh:
DECLARATION- AKU JANJI
INTERESTS AND ACTIVITIES
My preferred countries are (kindly refer to tables above) - Negara-negara pilihan saya adalah (sila rujuk jadual diatas)
* We cannot guarantee your first choice but we will do our best! / Kami tidak memberi sebarang jaminan anda akan mendapat pilihan pertama anda.
Please state your preferred choice of AFS Programs: Departing in:
Sila nyatakan program AFS pilihan anda Berlepas pada:
Year Program (8 months or more) Program Setahun (8 bulan atau lebih)
Jun/Jul/Aug/Sept Jun/Jul/Ogos/Sep
Semester Program (4-8 months) Program Semester (4-8 bulan)
Intensive Program (4-11 weeks) Program Intensif (4-11 minggu)
(YR 2017)
Austria Sept ‘18 June ‘19 32,000 5
Belgium Flanders Aug ‘18 July ‘19 36,000 5
Bosnia Herzegovina Sept ‘18 July ‘19 36,000 5
Brazil August ‘18 June ‘19 36,000 5
China August ‘18 June ‘19 32,000 5
Denmark August ‘18 June ‘19 35,000 5
Finland August ‘18 June ‘19 34,000 5
France Sept ‘18 July ‘19 38,000 5
Germany Sept ‘18 July ‘19 41,000 5
Hungary August ‘18 July ‘19 34,000 5
Italy Sept ‘18 July ‘19 32,000 5
Russia August ‘18 June ‘19 32,000 5
SEMESTER PROGRAM (4 – 8 MONTHS)
DESTINATION DEPART RETURN FEE (RM) FORM
(YR 2017)
Austria Jan ‘18 July ‘18 26,000 5
Brazil Feb ‘18 July ‘18 29,000 5
China August ‘18 Dec ‘18 24,000 5
France Jan ‘18 July ‘18 28,000 5
Hungary Jan ‘18 July ‘18 24,000 5
Italy Jan ‘18 July ‘18 26,000 5
INTENSIVE PROGRAM (4-11 WEEKS)
Finland June ‘18 July ‘18 20,000 3
Japan (School Based) Oct ‘18 Nov ‘18 20,000 3
Germany (Green Academy) July ‘18 August ‘18 23,000 3
Italy (Arts Program) June ‘18 July ‘18 22,000 3
Spain (Summer Academy) June ‘18 July ‘18 25,000 3
EDUCATORS PROGRAM
DESTINATION DEPART RETURN FEE (RM) WHO CAN APPLY
(YR 2017)
New Zealand Nov ‘18 Dec ‘18 15,000 School Teachers/
Educators
1) 2) 3)
AFS PROGRAMS PREFERENCE - PILIHAN PROGRAM AFS
IMPORTANT NOTES:
1. Please note that AFS Malaysia reserves the right to change the program fee and details without prior notice.
Programs Fee is inclusive of GST charges.
AFS Malaysia berhak menukar jumlah yuran serta syarat dan terma tanpa sebarang notis. Yuran program termasuk GST.
2. AFS Malaysia also reserves the right not to proceed with the program if it is deemed not viable or is cancelled by the host country.
AFS Malaysia juga berhak untuk tidak meneruskan program jika didapati ianya tidak sesuai ataupun dibatalkan oleh negara yang menawarkan program tersebut.
3. The RM 30.00 application fee is not refundable.
Yuran permohonan sebanyak RM 30.00 tidak akan dikembalikan.
4. Incomplete applications will be rejected.
Permohonan yang tidak lengkap tidak akan diproses.
5. All applications must be submitted to AFS Malaysia office as printed copies, applications submitted via online (via email) will not be considered.
Semua salinan permohonan perlu dihantar ke pejabat AFS Malaysia, penghantaran melalui atas talian (melalui emel) tidak akan dilayan.
6. Applicants must submit only photocopy of original documents. AFS Malaysia will not be responsible in sending back original copies.
Permohonan mestilah dihantar dengan salinan dokumen asal sahaja. AFS Malaysia tidak akan bertanggungjawab dalam memulangkan dokumen asal anda.
7. For any inquiries regarding AFS Program application, please email to info-mas@afs.org with the Subject Heading: AFS Application 2018 Inquiry.
Bagi sebarang pertanyaan berkenaan permohonan Program AFS, sila emel kepada: info-mas@afs.org dengan Tajuk Subjek: Pertanyaan Permohonan AFS 2018.
8. Students going on AFS programs need to comply with host country’s rules and regulations.
Pelajar-pelajar yang mengikuti program AFS adalah tertakluk kepada terma dan syarat yang ditetapkan oleh negara penempatan.
SUBMISSION POLICY /POLISI PENGHANTARAN
Send this completed application form on or before 30 November 2017 to:
Hantarkan borang permohonan yang lengkap sebelum atau pada 30 November 2017 kepada:
APPLICATION DEADLINE/ TARIKH TUTUP:
30 NOVEMBER 2017
SENDING DEPARTMENT AFS MALAYSIA
A-10-2, Block A, Plaza Glomac, Jalan SS 7/19, Kelana Jaya 47301 Petaling Jaya, Selangor Darul Ehsan Malaysia
