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2021-2022

ONLINE APPLICATION INSTRUCTIONS


Carefully read these instructions, and the instructions on each
of the forms, before you begin to fill out the application.

SECTION 1, Application Instructions:


• The online application form must be filled out in English.
• Applications not filled out completely will not be considered.
• On forms that require signatures, do not sign in English. Sign the same way you would sign any other document in your country.
Submit the complete online application form by the deadline listed on top of each Section. You can download a copy of the application form prior to its submission.

SECTION 2, Biographical Information:


STUDENT INFORMATION
• Primary Citizenship - If you are a citizen of more than one country, list all applicable countries.
• Primary Email Address - Please confirm the email address listed is one that you check often.
• Current Address – Write the actual address where you live. Do not translate the address. For example: ul. 8 Marta, not March 8 street.
• Other Telephone – Telephone number of another adult (not a parent) where you can be contacted. You must provide this information. You may write the telephone
number of a relative, older sibling, or a friend, but not a parent.
• United States Government English Access program Check the “yes” box if you participated in this program, or the “no” box if you did not.

SECTION 3, Family Contact Information:


You must include information about both parents. If you have a step-parent or legal guardian, indicate their relation to you and write their information.
• If your parent is no longer alive, choose DECEASED from the drop-down menu.
• If you do not know who or where your parent is, choose WHEREABOUTS UNKNOWN from the drop-down menu.

SECTION 4, School Information


• School Name: Write the official name of your school using transliteration. For example, If your school’s only name is a number, write “School #140.” If your school has a
name, write “Pushkin Lycee.” Do not translate the name into English.

SECTION 5, Host Family Letter:


• You may use a dictionary.
• Use only the space provided. You can use up to 600 words.

SECTION 6, Activities and Achievements:


• Activities, Interests and Sports: List activities you engage in on a regular, organized basis. Answer truthfully. Your host family may expect you to participate in these
activities in the United States.
• Describe what you like to do in your free time, aside from any regular, organized activities. Answer truthfully. Your host family may expect you to participate in these
activities in the United States.
• International Experience: If you have never participated in an international exchange program, or lived outside your country, DO NOT fill out that section.

SECTION 7, Confidential Recommendation From Teacher:


• Provide contact information of your teacher (Name and email address).
• Request recommendation: your teacher will receive a link to the recommendation form that needs to be filled out online.
• If you cannot choose a teacher you may ask the school director, or a teacher from a school you have recently attended.
• If your teacher knows English, they should fill out the recommendation form in English.
• If your teacher does not know English, ask the office in your country for this form in your local language.
• If your teacher does not have an email address or is not able to complete this form online, you should answer “No.” You will then be able to download the PDF version of this
form in English, to give to your teacher. Your teacher should complete the PDF and send it directly to the American Councils office in your country. Your teacher can contact
American Councils in your country if s/he has any questions.
• Neither the student nor a member of the student’s family may translate the form for the teacher.

SECTION 8 and 9, Placement Information:


• Answer these questions honestly. This information is only used to find American host families for exchange students and is not used during the selection process.
• If you answer yes to questions 11, 12, 16, 19, 21, 22, 23, 24, 25 or 27 an explanation must be provided.
• Questions 26 and 29: In order to participate in the program, you must agree to honor the laws and restrictions concerning smoking in the U.S. If you do not
sign this statement, your application will not be considered.

SECTION 10, Upload Candid Photos:


• Upload (2) current photos to this section showing you and your family or friends. Indicate which person is you and your age.
• Make sure your face can be seen in the picture.
• Photos should not display cigarettes, alcohol, revealing clothing or bare stomachs, or weapons (knives, guns).
• You must also upload a selfie.

SECTION 11, Upload Documents:


In order for your application to be considered, you must download the following six (6) documents, and then complete and upload them in the same section
by the due date indicated on your application.
1 Student Grade Transcript Form:
• This form must be signed by the director and have your school stamp. If school stamp is not provided, please explain why (i.e., COVID-19).
• If you attended two (2) schools in the past three years, make one photocopy of Form 5 and give it to the director of the other school to fill out, sign and stamp.
• If your current school has your official grades from the previous school you attended, then your current school principal may enter and approve those grades.
• Academic Year Class: Write your class at the top of each column.
• Grading Scale: Write the grading scale that is used at your school. For example, 1-5, 1-10, 1-12, or 1-100.
2021-2022
ONLINE APPLICATION INSTRUCTIONS

• Provide final grades for the last two years (2018-2019 and 2019-2020) and current grades for the first part of the 2020-2021 school year. Finalists will be required
to provide two years’ worth of original transcripts.
• Indicate the number of hours per week you spent in each class.
2 Parent/Student Agreement Form:
• The English form must have your signature, the signature of one of your parents or legal guardian, and the date that Form 8 was signed.
• The English form should be included with your application.
• Your parents should keep a copy of this form for their reference.
3 Privacy Policy Statement Form:
• You and one parent, or a legal guardian, must sign and return this form.
4 Permission for Care of My Child Form:
• The first side, Permission for Care of My Child, allows you to receive emergency medical treatment.
• It MUST be signed by a parent or legal guardian. This form may not be signed by a relative who is not your legal guardian.
5 Participant Consent & Release Form:
• This is your agreement that the U.S. Department of State has the right to use media containing your likeness or name.
• Signing this form is OPTIONAL.
• If you do not agree you do not need to upload this document.
• If you agree, both you and a parent or legal guardian must sign this.
6 Student Health Certificate Form:
• If your doctor does not know English, s/he can use a local language form provided by American Councils. In this case, send BOTH the signed local language
form AND the signed and stamped English language form.
• You may attach an extra page to Form M if there is not enough space to explain an illness or other health related issue.
PART A: Acknowledgment:
• A parent or legal guardian must complete AND SIGN this section.
• If you were unable to see your doctor to complete this form, due to Covid-19, indicate that by checking the box by this question. Then indicate who filled out the
form. If it was someone other than you, the school nurse, or a parent, write down who it was, using their title, not their name.
PART B: Medical Certification:
SECTION 1 • This is your medical HISTORY (any medical issue you had in the past). The doctor must provide an explanation for any question answered YES.
SECTION 2 • This section must be filled out completely and accurately. Your doctor should write only the date of each immunization. Do not indicate the
amount of the dose, or the brand name of the vaccine.
• If you have not received an immunization, the doctor should leave that space blank.
SECTION 3 • 3.1 TB testing: You must provide the results of a tuberculosis skin test OR an approved blood test performed after September 1, 2020. You do not
need to provide both. Choose one.

If you choose OPTION 1, SKIN TEST: If you choose OPTION 2, BLOOD TEST:

• Your doctor MUST indicate A) the date the skin test was administered; QuantiFERON®-TB Gold, and T-SPOT®.TB test are the only tests accepted.
B) the date the results were read; and C) the size IN MILLIMETERS of Your doctor must provide a lab report showing the QuantiFERON or T-SPOT
the induration. blood test results. This extra document must be included with your submitted
• Results need to be read within 48-72 hours of the skin test placement. application.
Results read before 48 hours or after 72 hours, are invalid. • Your doctor must indicate, in the Option 2 section, the date and the results of
• If the result of the skin test is 10 mm or larger, you must then go get a the blood test.
chest x-ray, and provide the date and result of the chest x-ray in • If the results are positive, indeterminate, or borderline, you must then go get
Section 3.2. a chest x-ray, and provide the date and result of the chest x-ray in section 3.2.

• 3.2 Chest x-ray: A chest x-ray is required if the skin test results were 10 mm or larger OR if the blood test was positive, borderline, or
indeterminate. All chest x-rays must be administered AFTER the skin test or blood test.
SECTION 4: • Your doctor must check yes or no for each symptom in sections 4.1 - 4.6.
• If your doctor marks YES to any of these symptoms, you must then get a chest x-ray and provide the date and result in section 4.7.
SECTION 5: • This is your CURRENT medical status (any active medical issues that you have). Your doctor must provide an explanation for any question
answered YES.
• Your doctor also needs to indicate, in this section, if you are allowed to participate in school sports.
SECTION 6: • The doctor must provide an explanation for any question answered YES.
• If any allergen is checked on 6.7, a description of the reaction and treatment needed must be provided.
• The doctor must indicate the general state of your health by checking the box for “EXCELLENT,” “GOOD,” or “POOR.”
• The English version of Form M must contain the physician’s signature, the date s/he signed the form and the physician’s or medical
institution’s stamp. If stamp or physician’s signature are not provided, please explain why (i.e. COVID-19).
• The English version also must include ALL of the information written on the local language version.
PART C: Dental Certification:
• The English version of Form M must contain the dentist’s signature, the date s/he signed the form and the dentist’s stamp. The dentist must answer all of the
questions, and explain where indicated.
AC2020APP007