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Rotary Youth Exchange Long-Term Program Application

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Submit completed application to:

Instructions for Rotary Youth Exchange Program Application
Read all directions on each page carefully before completing the application. Use the checklist on the inside back cover to ensure that you have completed all sections and obtained all necessary signatures.

If you are accepted as anexchange student, this application will be sent to your host country and will serve as your introduction to the people who are being asked to host you.

Components of Your Application
Your application consists of: • • • All forms in this application Copy of your passport or birth certificate Copy of your school transcript

Filling Out Your Application
Your application must be legible. Typed orcomputer-generated applications are strongly preferred. Answer all questions completely and as asked (do not write “same,” “see above,” or “see page __”). Enter your information directly onto the application unless directed otherwise. Make sure to use correct grammar and spelling. Wherever the application asks for your full legal name, enter your name exactly as it appears on your passport or birthcertificate. On pages that have a box in the upper right-hand corner marked “Applicant Name,” enter your preferred form of your name. For example, an applicant whose full legal name is Joseph David Smith might enter Joseph Smith or Joe Smith.

Making Photocopies and Signing Forms
You will need to submit four complete sets (your original plus three photocopies) of this application. (You may alsowish to make an additional set for your own records.) Sets 2-4 can be good-quality photocopies. All signatures on all sets must be signed in BLUE ink. To accomplish this: 1. 2. 3. 4. Complete the application form. Do not sign it. Make three good-quality photocopies of the completed application. Sign all four sets yourself, then have your parents/legal guardians sign all sets. Medical and dentalforms: Ask your physician and dentist to make three copies of the completed medical/dental form before signing it and then to sign each copy in blue ink. (It’s a good idea to include a blue pen when you give them the form.)

All attached photographs must be originals or good-quality color copies.

Questions?
If you have any questions about completing this application, check with your schoolcounselor or your local Rotary club’s Youth Exchange officer. Once you’ve completed your application, return it to your local Rotary club/district as they’ve instructed. District : Attach any additional instructions. If none, please check here:

Statement of Conduct for Working with Youth
Rotary International is committed to creating and maintaining the safest possible environment for allparticipants in Rotary activities. It is the duty of all Rotarians, Rotarians’ spouses, partners, and other volunteers to safeguard to the best of their ability the welfare of and to prevent the physical, sexual, or emotional abuse of children and young people with whom they come into contact. Adopted by the Rotary International Board of Directors, November 2002

District

Long-Term Exchange ProgramSmile!
Attach a recent, good-quality color photo of yourself (head and shoulders). Original photos or color copies must accompany all four sets of the application. Size: 2 x 2 in. (5 x 6.5 cm)

Personal Information
Before you begin your application, please read all instructions on the opposite page.
1. Applicant Information
Full Legal Name as it appears on passport or birth certificate(use all capital letters for your FAMILY name) Home Address — Street Preferred Name

Gender

Male

Female

City

State/Province

Postal Code

Country

Postal Address (if different) — Street

City

State/Province

Postal Code

Country

Home Phone

Mobile Phone

E-mail

Date of Birth (e.g., 01/Jan/1999)

Place of Birth (City, State/Province, Country)

Citizen of...
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