Student: Complete the top section of this form, then give the form and a preaddressed stamped envelope to a school representative who knows you and
your abilities and accomplishments at school. By so doing, you give permission to the school to release this information to the Rotary club/district Youth
Exchange committee for their review.
Applicant’s Full Legal Name Gender Date of Birth (e.g., 01/Jan/1999)
Male Female
Address — Street
City State/Province Postal Code Country
Home Phone Mobile Phone E-mail
Evaluator: This student is applying for a one-year educational study abroad program under Rotary club/district sponsorship. Please complete and forward
this form within