:

Family Name: Given Names:
Preferred Name: Date of Birth: Sex:

Address
Street: City: State: Postcode:
Phone: Fax: Email:

Place of Birth
City: State: Country:
Religion: Citizen of:
Do you have any
dietary restrictions?:
(If yes, explain)
What medical treatment
have you required in the
past year?


Parents or Legal Guardians
Father's Name: Mother's Name:
Address: Address:
Home Ph: Home Ph:
Occupation: Occupation:
Business Ph: Business Ph:
Fax: Fax:
Rotary member? Rotary member?
Name of Club: Name of Club:

Siblings
   Name Sex Age Occupation Living At Home?
1
2
3
4


Country Preference:

Exchange agreements are currently in place with Rotary Districts in the following countries.
However, alterations can occur according to prevailing conditions

Note: it is not possible to guarantee placement in any chosen country.

Arrange your choices in order of preference below.
To add a country to your choice list, double click their name.
To remove them from your choice list, double click them.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
   


Applicant's Personal background
(Please answer honestly)

Do you smoke? Do you drink alcohol?
Ever been involved with drugs? Have a steady boy/girlfriend?

What recreation/hobbies do you have, and how many hours do you devote to them each week?



Applicants School Activities

How much time away from school do you devote to studying, homework etc?

List any non-academic activities that you are involved with at school (school choir, community service etc)



School name:
Address:
Year you finish high school:
Number of students: Number of grades:
Languages studied: For how many years:

What responsibilities have you had at school (clubs, office etc):



List your sporting & cultural activities (describe ability level for each):




When you click "Submit", below, you will download a PDF document with the informtion you have entered. You MUST obtain the required signatures and bring this form with you to the interviews. Any information you did not have whilst completing this form needs to be added by hand, and input at the interview.