5. Secondary School Information
6. Languages
Native Language:
Proficiency (indicate Poor, Fair, Good, or Fluent)
Non-native Language(s) Years Studied Speaking Reading Writing
7. Sponsor District and Club Contacts
Name of Sponsor District Youth Exchange Chair Name of Sponsor Club Youth Exchange Officer
Address — Street Address — Street
City State/Province Postal Code Country City State/Province Postal Code Country
Home Phone Mobile Phone Home Phone Mobile Phone