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Pan Africa Youth Leadership Program

Student Application
Program Description: The Pan Africa Youth Leadership Program (PAYLP) is a three-week exchange from
dates if known in the United States for high school students and adult mentors. The primary program
themes are civic education, community service, entrepreneurship, and youth leadership development.
Participants live with host families for the majority of the exchange and engage in leadership and civic
education workshops, community service activities, visits to local schools and community organizations,
project planning and development, and local cultural activities with American peers. Participants return
home with action plans to bring their exchange experience to their home communities in the form of a
wide range of community service projects.

Eligibility requirements:
✓ Be a citizen or legal resident living in Mozambique (applicants with dual U.S. citizenship will not
be considered)
✓ Be between 15 and 18 years old by exchange start date and be able to attend at least one
additional semester of high school in their home community;
✓ Have proficiency in English
✓ Demonstrate good academic performance, an interest in community service and volunteer
activities, leadership potential, good communication, and a positive attitude;
✓ Work cooperatively in a team setting and appreciate the opinions of others;
✓ Have permission from parent(s) or legal guardian(s) to participate in the program.

We encourage people with disabilities and from other diverse backgrounds to apply. Opportunities are
open to people regardless of their race, color, national origin, sex, religion, socioeconomic status,
disability, sexual orientation, or gender identity.

Application Deadline: December 17th ,2023

Applications should be submitted to: [email protected]

Questions should be addressed to: [email protected]

Instructions for completing this application: Fill out the application and answer all questions carefully and
completely. The information you provide on this application will provide the basis for selecting participants
for this program. Semi-finalists will be contacted for a virtual interview.

There is no application fee. The U.S. Government will pay for all costs to participate in the program,
including international travel to and from the United States, passport fees, orientations, and the exchange
activities in the United States, including meals and lodging.

Youth Leadership Program – Student Application

This application is free of charge and may be duplicated.
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Pan Africa Youth Leadership Program

Student Application

PERSONAL INFORMATION

Ibraimo Nabila Nazir Borge

Name_________________________________________________________________________
Last (Family) First Middle
Beira city
Current Address: ________________________________________________________________
Beira,Mozambique,2100
City, State, Postal Code___________________________________________________________
Beira
Mailing Address (if different you’re your current address):_______________________________
Beira,Mozambique,2100
City, State, Postal Code___________________________________________________________
845675661
Home Phone _______________________________Mobile 870735410
Phone________________________
[email protected]
Email _________________________________________________________________________
04`19`2006
Date of Birth (mm/dd/yyyy) _________________Age at the time of application:17
___________
Mozambique,province of sofala,city of beira
City and Country of Birth _________________________________________________________
Mozambique
Country of Citizenship or Permanent Legal Residence___________________________________
Do you have dual citizenship? [ ] Yes [ ] No
If yes, indicate countries where you are a dual citizen: ____________________________
Gender: [ ] Male [ ] Female [ ] Other/Prefer to Self-Describe: ______________
Have you ever participated in an exchange program sponsored by the U.S. Department of
State? [ ] Yes [ ] No
If yes, provide the name of the program and date you participated: _________________

PARENT/GUARDIAN INFORMATION
**Your parent or guardian must sign the application at the end**
Parent/Guardian 1
Nazir De Sousa ibraimo
Name ________________________________________________ my father
Relation to you ___________
City of Beira,Matacuane Neighborhood
Address (if different from yours) _____________________________________________________
848247371
Phone _________________ [email protected]
Email ________________________ Mechanic
Occupation______________
Parent/Guardian 2
Egna Saquina Borge
Name ________________________________________________ My mother
Relation to you __________

Youth Leadership Program – Student Application

This application is free of charge and may be duplicated.
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City of Beira,Matacuane Neighborhood

Address (if different from yours) ___________________________________________________
847475321
Phone _________________ [email protected]
Email ________________________ Domestic
Occupation______________
PASSPORT INFORMATION
Do you have a valid passport? [ ] Yes [ ] No
If yes, please attach a copy of your passport to your application.
You do not need to currently possess a passport in order to submit your application to the
program. However, please be advised that a passport, valid for 6 months after the program end
date, is required for participation. If selected, the program will cover your costs to obtain a
passport if you don’t already have one.

Full name as on your passport_____________________________________________________

Passport Number __________________________ Expiration Date (mm/dd/yyyy)__________
Issuing Country ____________________________

TRAVEL INFORMATION
Have you ever traveled to the United States? [ ] Yes [ ] No
If yes, please provide a brief description of dates, length and nature of your stay(s), and
whether you obtained a visa:
_____________________________________________________________________________
_____________________________________________________________________________
Have you ever traveled outside of your country? [ ] Yes [ ] No
If yes, please provide a brief description of dates, length and nature of your stay(s):
_____________________________________________________________________________
_____________________________________________________________________________

ACCOMMODATIONS

It is the goal of the Pan Africa Youth Leadership Program and its partners to ensure the full and
equal participation of everybody regardless of gender, race, sexual preference, disability, or
otherwise. It is our policy to make necessary, reasonable accommodations to ensure that our
programs are accessible.

Youth Leadership Program – Student Application

This application is free of charge and may be duplicated.
 4

Would you require a reasonable accommodation, as a result of a physical or mental

impairment, to enable you to access the full benefit of this program? [ ] Yes [ ] No
If yes, use this space below to describe accommodations that could support you on program:
______________________________________________________________________________
______________________________________________________________________________
EDUCATION AND ACTIVITIES
Catholic Univeraity of Mozambique
School name___________________________________________________________________
private
School type (public, private, other)__________________________________________________
Ponta gea
School address__________________________________________________________________
Beira,Mozambique,2100
City, State, Postal code___________________________________________________________
first year
Current grade _____________ setember of 2027
Month and year you will graduate______________________
dental medicine or port management
Academic subjects you are most interested in _______________________________________
_____________________________________________________________________________
dental medicine
Future studies and/or possible occupations you’ve considered _________________________
_____________________________________________________________________________
Please list all extracurricular or volunteer activities you currently take part in. Include how long
you have been involved with each, and any awards or honors.
Examples: school clubs, sports teams, youth organizations, community service activities,
leisure time activities.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
LANGUAGE
What is your native (maternal) language? If you are bilingual, please list both of your
my native languages is portugues and my secondary language is ingles
native/maternal languages________________________________________________________

Youth Leadership Program – Student Application

This application is free of charge and may be duplicated.
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List other languages you have studied below.

english
Language_____________________________Number 5 months
of years studied_______________
Language_____________________________Number of years studied_______________
SHORT ESSAYS: Please respond to the following short essay questions in one paragraph

What motivates you to apply to the Pan Africa Youth Leadership Program? How will your
participation in the program help you address the issues currently facing your community?

i want to help and ssupport my community by changing the way they live . Especially to minors

In what ways are you an effective leader? Describe how you are a leader in your school,
community, or home.

i am a lider at home and school , supporting people to do the right thing and following them step by stepi have

During this exchange, participants will act as ambassadors for their countries. What
qualities do you have that would help you fulfill this role?

i have qualities such as ,being good at leadrship, and good argumentative skills

Upon your return home, you are asked to implement a community service project individually
or in a small group. What idea(s) do you have for a project that would improve your
community?

when i return, i want to help the community directly ,helping children and teenagers to perform well at school
and influencing them not to give up on their studies

Youth Leadership Program – Student Application

This application is free of charge and may be duplicated.
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PARTICIPANT AGREEMENT/PARENTAL CONSENT

By signing below, I verify that all the information in this application is true. I agree that if chosen
to participate, I will participate in ALL program activities in the United States and Mozambique,
including the pre-departure orientation and follow-on activities. I also understand that I must
remain with the program throughout the entire exchange and that personal travel within the
United States during the program is not permitted.

Please note that the safety of participants and our communities is our number one priority. In-
person exchange is contingent upon the continued stabilization of the pandemic and the safety
of travel.

_____________________________________________________________________________
Applicant Signature Date

I permit my child to apply for and, if selected, to participate in this program.

17 december 2023
_____________________________________________________________________________
Parent/Guardian 1 signature(s) Date
17 december 2023
_____________________________________________________________________________
Parent/Guardian 2 signature(s) Date

Youth Leadership Program – Student Application

This application is free of charge and may be duplicated.
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Youth Leadership Program – Student Application

This application is free of charge and may be duplicated.