1. Applicant Information
Full Legal Name as it appears on passport or birth certificate
(use all capital letters for your FAMILY name) Preferred Name Gender
Male Female
Home Address — Street
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 (Country)
2. Parent/Legal Guardian Information
Full Name of Father/Legal Guardian Full Name of Mother/Legal Guardian
Address — Street Address — Street
City State/Prov. Postal Code Country City State/Prov. Postal Code Country
E-mail E-mail
Home Phone Mobile Phone Home Phone Mobile Phone
Occupation Occupation
Business Phone Fax Business Phone Fax
Rotarian? Yes No
If yes, name of Rotary club:
Rotarian? Yes No
If yes, name of Rotary club:
Check here if your parents are divorced or separated. Authorizations should be obtained from all parents/legal guardians and others who have legal
rights to decisions affecting the student’s participation.
Parent/legal guardian to contact first in the event of an emergency