Name
Legal Name *  
  Male  Female
Language
French   German  Japanese  Spanish Chinese
Ethnic name at village
E-mail Address
School
Current Mailing Address:
Street *  
City *  
State/Province
ZIP *  
Country *  
Home telephone
Work telephone
Best time to be contacted *  
When will you leave your current address
Permanent Mailing Address:
Street *  
City *  
State/Province
ZIP *  
Country *  
Do you have an United States Social Security Number? Yes     No
Native Language
Citizenship
Concordia College student: Yes  No
If yes, Concordia ID#
Amity Scholar: Yes   No
Information for international staff: If you are not currently authorized to work in the United States, please read the following paragraphs:

IMPORTANT: If you currently live in the United States, you must submit copies of your current visa documents.
Do not send originals. Please include a copy of white I-94 card (both sides), a copy of the pink IAP-66 form and a copy of the I-20 form if you are presently enrolled in an institution. If you are a resident alien, please include a copy of your resident alien card.

A non-U.S. citizen with an F1 student visa must obtain work authorization from the school's international student adviser.

Concordia College Students: You are eligible to be employed in the Academic-Year Weekend Program under your F1 student visa.
Education
High School
Name *  
City *  
State/Province
ZIP *  
Grad. Year *  
College/University
Name *  
City *  
State/Province
ZIP *  
Major(s) *  
Adviser's Name *  
Grad. Year *  
Language Training and Skills
World Language *  
Years in High School *  
College quarters/semesters *  
Proficiency
Beginner   Intermediate   Advanced   Fluent
Travel, study or residence abroad and dates (in target language)
Experience with Young People
Describe your experience caring for children: teaching, camping, counseling, tutoring (in target language) *
 
Occasionally students with special needs participate in our program. Describe your experience in caring for students with special needs. *
 
Previous Concordia Language Villages Experience
Language
Number of Sessions
Activities lead
Year(s)
Leader(s)/Dean(s)
Transportation
If you have your own car, are you willing to provide transportation for other staff members in your area?
Yes  No
If yes, number of people
Occasionally we need a volunteer driver for our Concordia Language Villages van. Drivers must be at least 21 years old, hold a valid driver's license, complete our van drivers' course, and have a satisfactory driving record as determined by our insurance carrier. Are you interested in being a driver?
Yes  No
If yes, driver's license number:
State of issue:
Birth date:
Activities
The following are among those activities offered during the program. Please indicate activities in which you would like to be involved.

Mark: Lead = I can LEAD this activity; Assist = I can ASSIST in this activity; Interested= I am especially INTERESTED in this activity
Arts and Crafts *
  		Culture *
  		Music *
 
Dramatics *
  		Nature and Outdoors *
  		Sports *
 
Dancing *
 
Indicate hobbies, special recreational interests or culture-specific activities not covered in the previous question.
If you could offer another activity, what would it be? *  
Other Information
How did you find out about Concordia Language Villages? *
 
Are you at least 18 years of age? Yes  No
Are you CPR (Cardiopulmonary resuscitation) certified? Yes  No
Expiration Date?
First-aid training? Yes  No
Other certification (fencing, waterfront, etc.)
Have you ever been convicted of a felony? *
 
(Your application will not be sent if you do not answer this question.)
References
Language teachers, work supervisors, and people who have seen you work with children are appropriate references. DO NOT choose relatives or people whose only relationship to you is a "friend."

Reference #1 *   Reference #2 *  
Address Address
City, State & ZIP City, State & ZIP
Your relationship to reference Your relationship to reference

IMPORTANT: We must have telephone numbers. References will be contacted.

Home telephone *   Home telephone *  
Work telephone *   Work telephone *  
E-mail address E-mail address

Acknowledgement
All applicants must read the statement below. Please acknowledge the statement by checking either I agree or I do not agree. Your application will not be accepted unless you complete this section.
I certify that the facts set forth in this application are true and complete. You are hereby authorized to make investigation of all statements contained in this application. I also authorize my former educators to release any information they may have regarding my application.

I have read, understand and agree to the material found in the "Policy Statement." With this in mind, I have a serious, personal commitment to the mission of Concordia Language Villages and to the development and safety of the young people entrusted to me. *