Rotary Youth Exchange Information Request

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Rotary Youth Exchange

kechan@earthlink.net

Rotary Youth Exchange Information Request Form

Thank you for your interest in Rotary Youth Exchange.

IMPORTANT: PLEASE READ!

Please enter the information requested in the form below. ALL ADDRESS FIELDS ARE REQUIRED if we are to process your request satisfactorily.

When you are satisfied that you have provided all the information needed, click on the 'submit' button at the bottom of the page. Your request will then be emailed to an official who will process it and forward it to a Rotary Youth Exchange Chair in your area who should be able to put you in touch with a local Rotary Club.

THANK YOU for your interest!

First Name *

Last Name *

Gender *

Male

Female

Date of Birth

4-Digit Year *		Month *		Day *

High School Name *

I am interested in: (check either or both)

Summer Exchange

Academic Year Exchange

Your Street Address *
Your Home Address

City *		State/Province *		Zip/Postal Code *

Country *

Evening Phone *
Please include country, city and/or area codes as appropriate

E-mail Address
Please Enter Your E-mail Address

I am interested in the following three countries:

First		Second		Third

Any comments for us that you would like to send along?
Enter Additional Comments

* Required to submit this form

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