Preliminary Application Form SH 2019 Borang Permohonan SH 2019

Preliminary Application Form SH 2019 Borang Permohonan SH 2019

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)

A photocopy of your IC (both side) (Compulsory)

Satu salinan kad pengenalan (kedua-dua belah) (Wajib)

Your past 2 years’ school results (Compulsory)

Keputusan peperiksaan terkini bagi 2 tahun lalu (Wajib)

A recent passport photograph of yourself (Compulsory) Gambar ukuran passport yang terbaru (Wajib)

My preferred countries are (kindly refer to page 6) - Negara-negara pilihan saya adalah (sila rujuk muka surat 6)

1) _____________________________________ 2) ___________________________________ 3) _____________________________________

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) Trimester Program (3 months) Program Trimester (3 bulan)

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.

Full name (as in IC) – Nama Penuh (seperti dalam K/P) Birth date – Tarikh Lahir 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: Identification Card (IC) Number – Nombor Kad Pengenalan:

Recent Photo Gambar Terbaru

CHECKLIST- SENARAI SEMAK

PERSONAL INFORMATION – MAKLUMAT PERIBADI

AFS PROGRAMS PREFERENCE - PILIHAN PROGRAM AFS

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 school / Sekolah berasrama Penuh

 International School / Sekolah Antarabangsa

 Religious School / Sekolah Agama

 Private School / Sekolah Swasta

 Special Education School / 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/GUARDIAN(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?

5. Tell us about your hobbies and interest. / Sila nyatakan hobi dan minat anda.

** Your personal statement should be between 300-400 words ONLY / Kenyataan diri anda haruslah di antara 300-400 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

__________________

 Who is your referral? Siapakah yang mengesyorkan AFS Program kepada anda?

_______________________________________________________________

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

As part of AFS Malaysia‘s commitment to help your dream come true, we offer various scholarships that you could be eligible for!

Sebahagian dari komitmen kami di Yayasan AFS Antarabudaya Malaysia adalah untuk membantu menjadikan impian anda kenyataan dengan menawarkan pelbagai biasiswa.

Scholarship available:

Biasiswa yang ditawarkan:

SOUTHERN HEMISPHERE (SH) CYCLE 2019/2020 (Jan - Jun Depart) YEAR PROGRAM (8 MONTHS OR MORE)

DESTINATION DEPART RETURN FEE (RM) AGE (YR 2019)

Argentina Feb ‘20 Jan ‘21 40,000 17

Brazil Feb ‘20 Jan ‘21 36,000 17

Chile Feb ‘20 Jan ‘21 32,000 17

China Feb ‘20 Dec ‘21 32,000 17

Denmark Jan ‘20 Dec ‘20 34,000 17

Germany Feb ‘20 Jan ‘21 41,000 17

Japan Mar ‘20 Feb ‘21 35,000 17

Switzerland Feb ‘20 Jan ‘21 45,000 17

Hungary Jan ‘20 Dec ‘20 32,000 17

SEMESTER PROGRAM (4 - 8 MONTHS)

DESTINATION DEPART RETURN FEE (RM) AGE (YR 2019)

Austria Jan ‘20 July ‘20 26,500 17

France Jan ‘20 July ‘20 28,500 17

Italy Jan ‘20 July ‘20 25,000 17

Spain Jan ‘20 June ‘20 28,000 17

Brazil Feb ‘20 July ‘20 29,000 17

Hungary Jan ‘20 July ‘20 25,500 17

China Mar ‘20 July ‘20 24,500 17

Poland Feb ‘20 July ‘20 25,500 17

TRIMESTER PROGRAM: PEACE PROGRAM (Jan - April)

DESTINATION DEPART RETURN FEE (RM) AGE (YR 2019)

Austria Jan ‘20 Apr ‘20 21,000 15-18

Iceland Jan ‘20 Apr ‘20 20,000 15-18

Poland Jan ‘20 Apr ‘20 20,000 15-18

Portugal Jan ‘20 Apr ‘20 20,000 15-18

Italy Jan ‘20 Apr ‘20 20,000 15-18

Belgium Flanders Jan ‘20 Apr ‘20 20,000 15-18

Bosnia Herzegovina Jan ‘20 Apr ‘20 20,000 15-18

Egypt Jan ‘20 Apr ‘20 20,000 15-18

Slovakia Jan ‘20 Apr ‘20 20,000 15-18

INTENSIVE PROGRAM (UP TO 4 WEEKS)

DESTINATION DEPART RETURN FEE (RM) AGE (YR 2019)

Italy Dec ‘19 Feb ‘20 18,000 15-17

Japan (Language) Dec ‘19 Dec ‘19 21,500 15-17

Japan (School Based) Oct ‘19 Nov ‘19 18,000 15-17

Turkey Dec ‘19 Feb ‘20 18,000 15-17

Germany (Winter STEM) Jan ‘20 Feb ‘20 22,500 15-17

Denmark (Ranum Efterskole) Jan ‘20 Feb ‘20 22,000 15-17

Yayasan Antarabudaya Malaysia (YABM)

This is a partial scholarship open to all students who wish to go on the Year Program.

Preferences will be given to those applying for non-English speaking countries. Terms and conditions apply.

SCHOLARSHIPS

For the scholarship available, please refer to page 6.

Sila rujuk muka surat 6 bagi biasiswa yang boleh dipohon.

If you wish to apply for any of our scholarship, please complete the scholarship section below.

Jika anda ingin memohon untuk sebarang biasiswa sila lengkapkan bahagian di bawah.

I am applying for the following scholarship(s) for which I am eligible for:

Saya layak untuk memohon biasiswa berikut:

Name of Scholarship(s):

Nama Biasiswa:

Family Annual Income (Please tick):

Pendapatan tahunan keluarga (Sila tandakan):

 Up to RM30,000 / Sehingga RM30,000  RM31,000-RM50,000  RM51,000-RM70,000

 RM71,000-RM99,000  RM100,000 and above/

Lebih dari RM100,000

Number of dependents /Jumlah tanggungan: ________________________________________________________________________

I deserve a scholarship because… (Not more than 30 words) / Saya layak untuk menerima biasiswa kerana… (tidak melebihi 30 perkataan)

Please note that this scholarship application does not automatically guarantee you an AFS Scholarship. Your application will be reviewed by the AFS Selection Committee to determine your eligibility. However, you may still participate as a fee-paying candidate if you are unable to secure a scholarship.

We trust that your information in this application is valid, failing which your application will be disqualified.

Sila maklum bahawa permohonan biasiswa ini tidak menjamin biayaan Biasiswa AFS secara otomatik. Permohonan anda akan ditapis oleh Jawatankuasa Pemilihan AFS bagi menentukan calon yang layak. Bagaimanapun, anda masih boleh menyertai program ini sebagai calon berbayar, sekiranya anda tidak terpilih untuk biasiwsa ini.

Sekiranya didapati sebarang maklumat yang diberi tidak benar, permohonan anda akan dibatalkan.

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:

SCHOLARSHIP APPLICATION – PERMOHONAN BIASISWA

DECLARATION- AKU JANJI

SUBMISSION POLICY /POLISI PENGHANTARAN

Send this completed application form on or before 31 April 2019 to:

Hantarkan borang permohonan yang lengkap sebelum atau pada 31 April 2019 kepada:

APPLICATION DEADLINE/ TARIKH TUTUP:

31 April 2019

More info: www.afs.org.my Email: info-mas@afs.org

Phone: 03-7887 6866

IMPORTANT NOTES:

1. Please note that AFS Malaysia reserves the right to change the program fee and details without prior notice.

AFS Malaysia berhak menukar jumlah yuran serta syarat dan terma tanpa sebarang notis.

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. Short listed candidates will be called for an interview in May/June 2019 (interview may be held during school holidays). Request to change date and venue will not be entertained.

Pelajar yang disenarai pendek akan dipanggil untuk menghadiri temuduga pada bulan Mei/Jun 2019 (temuduga berkemungkinan diadakan semasa cuti sekolah). Permohonan untuk menukar tarikh atau tempat temuduga tidak akan dilayan.

6. 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.

7. 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.

8. For any inquiries regarding AFS Program application, please email to info-mas@afs.org with the Subject Heading: AFS Application 2019-2020 Inquiry.

Bagi sebarang pertanyaan berkenaan permohonan Program AFS, sila emel kepada: info-mas@afs.org dengan Tajuk Subjek: Pertanyaan Permohonan AFS 2019-2020.

9. 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.

SENDING DEPARTMENT AFS MALAYSIA

A-10-2, Block A, Plaza Glomac, Jalan SS 7/19, Kelana Jaya 47301 Petaling Jaya, Selangor Darul Ehsan Malaysia

Cheque/Money/Postal Order payable to:

Yayasan AFS Antarabudaya Malaysia