Teach USA Application Form to use for testing our email notifications "*" indicates required fields Partner information Sending Partner Organization Name (if applicable): Today's Date MM slash DD slash YYYY *Remember: Participants must commit to their teacher placement for the entire program duration! General Information (as it appears on your passport): Personal information Last Name (Family Name)* First Name (Given Name)* General InformationSex: Male Female Date of birth:* MM slash DD slash YYYY City of birth:* Country of birth:*Country of birth: Country of legal permanent residence:* Country issuing passport:* Do you have friends or family residing the US? (If “yes” please fill in the information below)* Yes No Relationship to you: Where are they located? Contact information Permanent Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Telephone:Skype ID: Email:* Enter Email Confirm Email Program information Program Information*Program option: Greenheart Exchange Full Program Self Placed Program start date:* MM slash DD slash YYYY Program end date:* MM slash DD slash YYYY Name of sending organization:* What subject area do you intend to teach?* Emergency information Emergency Contact Information (2 emergency contacts are required; one emergency contact must speak English)* First Last Relationship to the participant:* Telephone # (including country/city code):*Language(s) Spoken:* Secondary Emergency Contact* First Last Relationship to the participant:* Telephone # (including country/city code):*Emergency contact – two language*Language(s) spoken: Additional information *J-2 Dependent General Information (If you are married and/or you have children and plan to bring them with you to the US, complete the fields below AND submit a J-2 Application for each as an attachment):Are you bringing any children as dependents?* Yes No How many children? (you will need to complete a separate J-2 application for each dependent)Please enter a number greater than or equal to 0.Are you bringing your spouse / partner? Yes No Sex of your partner or spouse: Language skills Language Skills:*Language: Speaking*NativeExcellentGoodAveragePoorWriting*NativeExcellentGoodAveragePoorSecond Language:Language SpeakingNativeExcellentGoodAveragePoorWritingNativeExcellentGoodAveragePoorThird Language:Language SpeakingNativeExcellentGoodAveragePoorWritingNativeExcellentGoodAveragePoor Medical information *Medical Information and Release:Medical Information and Release:*Do you have any pre-existing medical conditions? Yes No Please list them: Do you have any conditions that would deter you from performing your teaching duties (i.e. pregnancy)?* Yes No Please list them: Do you have any allergies?* Yes No Please list them: Are you currently taking prescribed medications?* Yes No Please list them: Have you ever required special treatment for drug addiction or any medical or psychological disorders?* Yes No Please list them: *Medical Release: In the event of an emergency situation requiring medical treatment, I hereby grant permission for any and all medical and/or dental attention to be administered to me, under the general supervision of licensed medial staff and emergency room staff.Medical Release*Agreement: I agree Today's Date (for Medical Release):* MM slash DD slash YYYY Files and agreement information *File Upload SectionCopy of Passport (PDF):*Accepted file types: pdf, Max. file size: 80 MB.Photo (passport size):*Accepted file types: jpg, png, pdf, Max. file size: 80 MB.Reference Letter 1:*Accepted file types: pdf, doc, docx, odt, Max. file size: 80 MB.Reference Letter 2:*Accepted file types: pdf, doc, docx, odt, Max. file size: 80 MB.Proof of a degree equivalent to a U.S. bachelor’s degree:*Accepted file types: jpg, pdf, png, Max. file size: 80 MB.Proof of qualification to teach in your home country:*Accepted file types: jpg, png, pdf, Max. file size: 80 MB.Proof of sufficient finances for living and housing expenses: Financial Resources Verification (FRV) form.Accepted file types: jpg, png, pdf, Max. file size: 80 MB.Counter-signed job offer letterreceived by Greenheart Exchange no more than 7 days after placement is sent: Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 80 MB.Signed HSA Agreement*(please download, fill, collect signature, and upload our Host School Agreement)Accepted file types: pdf, Max. file size: 80 MB.Signed Terms and Conditions* (please download, fill, and upload our Teach USA Participant T&C Form)Accepted file types: pdf, Max. file size: 80 MB.Unsigned Offer Letter:Accepted file types: jpg, doc, docx, pdf, Max. file size: 80 MB.Host School Website: Brochures/marketing materials if host school does not have an active websiteBrochures/marketing materials if host school does not have an active websiteAccepted file types: jpg, png, gif, pdf, doc, docx, Max. file size: 80 MB.Copy of host school medical insurance coverage, including the name and contact information of the insurance company, the policy number, name and contact information of the claims office(s), as well as medical emergency proceduresCopy of host school medical insurance coverage, including the name and contact information of the insurance company, the policy number, name and contact information of the claims office(s), as well as medical emergency proceduresAccepted file types: pdf, doc, docx, jpg, Max. file size: 80 MB.FileAdditional J-2 Applications for each dependent (PDF): Drop files here or Select files Max. file size: 80 MB. Signature: Please type your first and last name here* * I certify the information I provided on and in connection with this form is true, accurate and complete Today's date:* MM slash DD slash YYYY
