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CAPAY
c/o Asian American Studies Program
at University of Massachusetts Boston
100 Morrissey Boulevard
Boston, MA 02125
ph: 617-287-5658______________fax: 617-287-5622
web: http://fly.to/capay
CAPAY Community YouthLearn Program
Member Application

Background Information
CAPAY's Community YouthLearn Program is committed to developing the capacities of Asian Pacific American (APA) young people and reconnecting the APA communities for a better sense of leadership and community development. Community YouthLearn Members provide multi-cultural, multi-lingual support to APA communities through a wide range of opportunities. Community YouthLearn Members learn about Asian American history and current issues, intern at community based organizations in Asian communities, design and organize community projects, and support CAPAY's Annual Leadership Symposium. CAPAY is seeking committed high school students to serve as YouthLearn Members.

Applicants should be high school students age 15 years and older, and be able to give a one-year commitment when completing this application. Mail or fax application to CAPAY, c/o Asian American Studies Program, UMass Boston, 100 Morrissey Blvd., Boston, MA 02125-3393. Fax number: (617) 287-5622

Deadline for applications: MAY 31st
Please type or print neatly in ink
A) Applicant Profile

Last name: ______________________________________First name: _____________________________________

Home address: ____________________________________________________________________________

City: _________________________________
State: ______
Zip: _________________________

Telephone: __(______)________________________
Email: _____________________________________________

Sex: Female____ Male ____
Date of birth: __________________

Ethnicity: ______________________________
Social Security Number: _________________________________

US Citizen:____ National:____Permanent Resident:____
other: ___________________________________

Grade: _______
School/GED Program currently enrolled:__________________________

Do you know a language other than English? No ___
If yes, what language(s)? ___________________________

Speaking Ability: Excellent______ Good______
Fair______
Poor______

Writing Ability: Excellent______ Good______
Fair______
Poor______

Reading Ability: Excellent______ Good______
Fair______
Poor______

Do you have any special needs that require accommodation? Yes______ No______

If yes, please specify: _________________________________________________________________________________

Have you ever been convicted of any criminal offense by a civilian or military court? (Do not include minor traffic violations)
Yes____ No____
if yes, please specify: ___________________________________

B) In case of Emergency, notify:
Name______________________________________________________________

Telephone______________________

Relationship___________________________

C) Statement from Applicant: (Please answer the following questions. Type or write neatly on additional sheets of paper.)

1) Why are you interested in becoming a Community YouthLearn Member?
2) Describe your previous community involvement and community service experiences.
3) It can be difficult to commit to one year of part-time service. What challenges will you face in doing so? What will you need to do to keep the commitment?
4) If you are selected as a Community YouthLearn Member, how do you see yourself making a difference in the Asian Pacific American communities and helping to make your community stronger?
5) If selected as a YouthLearn Member, what will be your personal goals for participating in this program? What do you hope to learn from this experience?

D) Other Information
Community YouthLearn Members are required to serve for at least one year (300 hours). Members will receive training approximately 2 hours per week and intern at a community organization site about 4 hours a week. Because some of the service projects as well as training will take place during weekends, weekend hours are mandatory and scheduling flexibility is required. Members will receive a small stipend based on the year's work.

1) Which community are you interested in being placed? Please check as many sites as possible. We will try to place you in one of your choices.
_____CAPAY at UMass Boston, projects include organizing community service projects and the Symposium.
_____Chinese community in Boston's Chinatown.
_____Vietnamese community in Dorchester.
_____ APA community in Malden

2) How did you hear about CAPAY's Community YouthLearn Program?
From Announcement Flyer ____Adult Counselor ____Peers/Friends ____Other______________________

3) What are some of your areas of interest (arts, media, music, science,sports, etc.)? _______________________________

___________________________________________________________________________________________________

E) Three references are required from people who know you well. (We will most likely be calling some or most of these people to ask them more about you. So let them know they are your references!) **
Name:________________________________________

Ph # where person can be reached:_________________________

Relationship to you:___________________________________________________________________________

Name:________________________________________

Ph # where person can be reached:_________________________

Relationship to you:___________________________________________________________________________

Name:________________________________________

Ph # where person can be reached:_________________________

Relationship to you:___________________________________________________________________________

** Recommendation letters are encouraged but not required. They can only help us get to know you better in this application process. If you choose to do this, include them with your application form.

Signature of Applicant________________________________________________ Date _________________

Signature of Parent/Guardian (If applicant is under 18 years old) ____________________________________ Date____________

If you have any questions about this application, please feel free to contact CAPAY at (617) 287-5658 and speak with Sophia Kim, Coordinator.


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