ApplicationforaRotaryYouthExchange
ShortTermProgram
Afteryou have interviewed and accepted atthe club level, submit application to:
Scott White
9762 Hanover Court East
Henderson, CO 80640
303 295 6000
FAX: 303 295 6101CELL: 303 503 3882
Readinstructionsonnextpagebeforecompletingapplication
Note:Additionalinformationmayberequiredforspecializedshortterm exchanges
Explanationofprogram
Eligibility: Thestudentmustbeatleast14,butnotmorethan18yearsofage atthetimeoftheexchange. ApplicantsmaybethechildrenofRotariansornon- Rotarians. AlocalRotaryclubmustsponsorthestudentanditisthe
responsibility of that club to determine whether the student is qualified. As well asbeingafunfilledexperiencethestudentmustbewillingtobeagoodwill ambassador for Rotary and the UnitedStates. Applicants should demonstrate the ability and willingness to fulfill the role of an ambassador.
Reciprocation:This is a reciprocal exchange. The student will spend approximately one month in the home of a family in a foreign country.In turn a student from that same home will spend a month in the home of the U.S. student. Itisimperativethatboththestudentandthestudent’sfamilyare educatedaboutandcommittedtothisprogram.Amongotherthings,thismeans that the family must committo showing their guest as much of our country as possible. Nothing extravagant is expected, however the family is expected to go out of their way to arrange weekend excursions, sporting events, community outings and other points of interest for their guest. The family should show its guest as good a time as they would want their child to have in the foreign
country they visit.
Timing:Generally exchanges occur from late June through August.
Gender:An effort is made to match boys with boys and girls with girls.But there is no guarantee. If this is important please note it in writing and include it with the application.
Procedure:AllinitialcontactsbythestudentarethroughthelocalRotaryclub. Once the application has been completed, the localclubwilldeterminewhether the student is qualified. Qualified applications will be forwarded to the district committee. The committee exchangestheapplicationwiththecommittee in the foreign country selected, and the matching process begins. As soon asa tentativematchismade,thecommitteewillcontactthestudentdirectlyto discuss the match. A copy of the foreign student’s application is provided to the USstudentandthetwoareinstructedtomakedirectcontact. Throughdirect contact,thestudentsandtheirfamiliesdiscussthefinaldetailsregardingliving accommodations, special needs, travel dates, etc. The student’s family must make the final confirmation of the match. The committee will host an orientation program for the outbound US students in the spring, and notify the insurance carrierofthestudent’straveldates.
TO:ROTARYCLUBYOUTHEXCHANGEOFFICERS FROM: SUMMER PROGRAM COMMITTEE
Scott White
9762 Hanover Court East
Henderson, CO 80640
303 295 6000
Please remember that unlike the year-long program there is no screening process for these students at the district level.YOU ARE THE SCREENING PROCESS! Once you recommend a qualified student to the district, we match the student with a family in their host country. When considering an applicant please ponder the following:
Would you want this student to live in your home for a month? Wouldyouwantyourchildlivinginthishomeforamonth? DoesthisstudentrepresentthebestofRotaryAmerica?
Inordertogivefamiliesthemaximumamountoftimetoplanthe exchange please deliver qualified applications to the district by January31.
AnorientationfortheapplicantsandtheirfamilieswillbescheduledforApril or May. Details to follow.
Thank you!
CountryPreferenceForm
The following is a list of countries with which Rocky Mountain Rotary Youth Exchangehasexchangedwithinthepastorexpectstoexchangewith in the future. However, this does notguarantee all of these countries are always available. Please circle all the countries you would be willing to go to. Draw a line through any countries you do not want to go to and put a star next to your top choices. Bear in mind the more countries you select the greater chance you have of being placed. Please email Michael Smith for updates and changes.
France
Italy Switzerland Argentina Germany Spain Sweden Finland Denmark Brazil Turkey
belgium
List other choices, not mentioned above
NameofApplicant:
NameofSponsoringRotary Club:
TO:Scott White
From: Rotary Youth Exchange Officer: ______
Rotary Club: ______
Phone: ______
Enclosed is the application for: ______
I certify that
____I have interviewed and determined the applicant to be qualified for this program
____I have reviewed, explained and provided a copy of the Explanation and
____All three (3) of the student’s applications have been signed by:
____Applicant
____BOTH parents OR non-signing parent is deceased or incompetent
____An authorized representative for this Rotary Club
I certify the following documents are complete and correct:
____Executed application form in triplicate
____Country Preference Form
____$95.00 check payable to Rocky Mountain Rotary Youth Exchange
____Explanations and Conditions form signed by applicant and both parents
______
Youth Exchange OfficerDate
InstructionstotheApplicantandChecklistfortheApplication
Applicant’s Name:
SponsoringClub:
Complete the original application form, exceptthesignaturesandphotos.
Maketwophotocopiesofthecompletedapplicationformonly.
Attach 1 passport photo to each of the 3 copies (see instructions on form, please don’t staple)
Applicantandbothparents sign allthreecopies:
Applicant
Father
Mother
Include a single photograph of yourself with your family and your home. (Please enclose in a plastic sheet protector) PHOTO WILL NOT BE RETURNED
Completeandattachthecountrypreferenceform.
Arrangefor three letters of recommendation addressed totheYouth ExchangeOfficerofyoursponsoringRotaryclub.Acceptablesourcesinclude teachers, clergy or employer.At least one of the three letters must be from aRotarian.
____ Signed by student
____ Signed by parents
____ Check for proper amount is attached
Attach a $95.00 check (NON-REFUNDABLE) payable to Rocky Mountain
Rotary Youth Exchange
SubmittotheYouthExchangeOfficerofyourSponsoringRotaryClub
Instructionsfor RotaryYouthExchangeShortTerm Program Application
Readthesedirectionscarefullybeforecompletingtheapplication. Ifyouareacceptedasanexchangestudent, this applicationwillbesentto yourhost country. Itwillserveasyourintroductiontothepeople whoarebeingaskedtohost you. Itisimportantthatthe firstimpressionyoumakebeagoodimpression. Completethisapplicationcarefully.All grammarandspellingshouldbecorrect.Andremember, neatnesscounts.
GENERALINSTRUCTIONS:
ThisapplicationprovideshostingRotaryClubsandDistrictsbasicinformation from whichshortterm youthexchange placementscanbe made. HostingRotaryClubsandDistricts mayaddadditionalpagestoobtaininformationapplicable forspecializedshortterm exchanges (suchascampsforstudentswithdisabilities, tours, NewGenerationsExchanges, etc.).Applicationsmustbelegible. Typedorcomputergeneratedapplicationsarepreferred.Answerallquestionsas asked. Donotwrite“same”or“seepage,”etc. Typeanswersontheapplicationexceptwhereotherwiseindicated. Practiceonadraft copyoftheapplicationtomakesureyouranswersfitinthespaceprovided.
Signatures:Allsignatures mustbeoriginalsand writteninBLUEinkonallfourcopies. Toaccomplishthis, completeone fullapplicationbutdonotsignit.Makethreecopiesandthensignall fourcompletedapplications. Thestudent’ssigna- tureisrequired2timesandparents’ signaturesarerequiredonceoneachcopyoftheapplication. Tohelpyoufind signaturelocations, allsignaturelocationshavebeenplacedinboxesandasterisked(*).
SPECIFICINSTRUCTIONS:
Page1: Address Thisshouldbethestudent’spostaladdress.
ApplicantandParents/LegalGuardian Allparentalinformation mustbecompleted. Ifyourparentsaredivorced, providetherequestedinformationforthenon-custodialparent, notyourstep-parent unlesshe/shehaslegalguardian- shipof youorhasformallyadoptedyou. Ifsomeoneother thanaparentisyourlegalguardian, providetherequested information forthelegalguardian.Authorizationsmustbeobtained from allparents/guardians. Emergencytelephone numbersmustbedifferentthanthehomeandbusinessphonenumbers. If yourparentshaveafax numberore-mail address, typeitinthespaceprovided.
DateofBirth Remembertousethealphabeticabbreviationformonth,e.g.,(1986/Feb/22);notthenumeric.Pleasenotethat thisannotationofdateofbirthistheInternationalStandardand maybedifferentfrom whatyouareusedto.
RotaryClubandDistrictEndorsement ThiswillbecompletedbyyourRotaryClubandDistrictYouthExchange Committee. Giveall4copiesto yourRotarycontactforsignature. Insomecases, theschoolarrangesfor this. Check with yourguidancecounselor. TheDistrictEndorsementwillbecompletedifandwhenyouareselected. ClubsandDistricts
—Pleasenotethatyoualsoneedtocompletethetoppart oftheSupplementalSection.
Page2: ProgramRulesandConditionsofExchange
Parentsandstudentsshouldreadthesecarefully. Youareexpectedtoabidebytheserulesandconditionsofexchange whileaparticipantintheRotaryYouthExchangeprogram. Failureto dosomayresultintheterminationofyourex- changeandearlyreturnhome.Allsignatures mustbeoriginals. Thisshouldbesignedinthepresenceofa RotaryClub representative.Note: Thesearerulesandconditionsjointlyagreedtoby mostRotaryDistricts. However, yourHosting Districtmayadd, modifyordeletesomeoftheserulesand/orconditions.YouwillbeinformedbyyourHostingDistrictof anychanges.
PermissionforMedicalCareandReleaseofLiability Readcarefully. If youareillandrequiremedicalcare, thisgives permission foryourhostfamilyand/orahostingRotariantoactforyourparentsorguardians. Thisholdsyournatural parentsresponsible foradditionalmedicalbillsandtransportationcostsnot coveredbyyourinsuranceifrequiredby yourillness. YouandBOTH parentsorguardiansmustsignwhereindicated. If yourparentsaredivorced, youmustget thesignatureofthenon-custodialparent unlesssomeoneelsehaslegalguardianshipof you.Authorizations mustbe obtainedfromallparentsandguardians.
EmergencyContact Providethenameandtelephone/fax ofafamilymemberorclosefriendofyourparentswhomay becontactedincaseofanemergencyifwecannot contactyourparents. Thisshouldbesomeone whoyourparentstrust tomakedecisionsaboutyourmedicalcarewhenyourparentsarenotavailable.
Pages3-4: SupplementalInformation(SponsoringClubandDistrictmust completethetoppart ofthispage) Answereachquestionsuccinctly. Givethoughttothemessageyouarecommunicatingto yourfuturehost cluband
family. Youmayadduptotwotypedpagesifneeded. Ifyouhavedietaryrestrictions, besuretostateclearlywhatyou
willnoteat. If yousmoke, drinkalcoholicbeveragesorhaveapast orcurrentinvolvementwithillegaldrugs, besureto
providetheexplanatoryinformationrequested.A“yes”answerwillnotautomaticallyeliminateyou, however, itwill
necessitatespecialconsiderationbythehostfamily.
Page5: Picturepage Affix thepicturestothepagewithglueordouble-sidedtape (donotstaple). Youmayeithermake colorcopiesofthepageorusealloriginalcopiesofthepictures.
Applicationfora
RotaryYouthExchange
District ______ShortTermProgram
TYPE theapplication, makethreecopiesand SIGNeach application in BLUE ink.All signaturesmust beoriginals.All datesare yr/mo/day.
Readthe Instructions first.
Applicant
Familyname/LegalnameFirst/Given nameWant tobecalledSex(M/F)
StreetAddressCity
State/ProvinceCountryofResidencePostalCode
Dateof Birth (yr/mo/day)CityofBirthState/Provinceof BirthCountryof Birth
Citizenof (Country)HomeTelephoneE-mailAddress
I, as the above applicant, hereby state that I amof good health and character, understand the importance ofthe roleof a youth ambassadoras a Rotary YouthExchange Student, have readand agree to abide by the Program Rulesand Conditions of Exchange detailed onpage2 of this application and will, tothe best of myability, maintain the high standards required of a Rotary Youth Exchange Student should I bechosen to represent mysponsoring Rotary cluband district, my school,community, state/province and country as an exchange student.
I furtherstate thatall the material contained inthisapplication and documents attachedheretoare trueand accurateto thebest ofmy knowledge.
Parents/Legal Guardians
NaturalFather’s name/LegalGuardianNaturalMother’s name/LegalGuardian
AddressAddress
Occupation / BusinessTelephone / Occupation / BusinessTelephoneHomeTelephone / EmergencyTelephone / HomeTelephone / EmergencyTelephone
Fax / E-mail / Fax / E-mail
Rotarian?Yes / No / If“Yes,” NameofRotaryClub / Rotarian?Yes / No / If“Yes,” NameofRotaryClub
Sponsoring Rotary Club andDistrict
The Rotary Clubof and District , having interviewed the applicant and his/her parents/legal guardiansand reviewed thestudent’s application, hereby endorse the student as meeting thequalifications forRotary Youth Exchange and recommendto hostingclubs the acceptanceof this student. The Districtagrees to provide adequateorientationto thestudent and parentsbefore departure, and will will nothostan Inbound.
Type- ClubPresident Type- ClubSecretary/YEO Type-DistrictYE Chairperson
Sign- ClubPresident Date Sign- ClubSecretary/YEO Date Sign-DistrictYE Chairperson Date
ProgramRulesandConditionsofExchange
1) Obey theLawsof theHostCountry — If found guilty of violation of any law, studentcan expectnoassistancefrom Rotary ortheirnativecountry.Studentwillbereturned homeassoon asreleased by authorities.
2) The studentisnotallowed to possessoruseillegaldrugs.
Medicineprescribed by a physician isallowed.
3) The studentisnotauthorized to operatea motorized vehicleof any kind which requiresa federal/state/ provinciallicenseorparticipatein drivereducation programs.
4) Theillegaldrinkingof alcoholic beveragesisexpressly forbidden. Studentswhoareof legalagein hostcountry should refrain.
5) Stealing isprohibited. Therearenoexceptions.
6) Unauthorized travel isnotallowed. Studentsmustfollow thetravelrulesof theHost District.
7) The student mustbecovered by a health and lifeinsur- ancepolicy agreeabletotheHosting District.
8) The student mustabideby therulesand conditionsof exchangeof theHosting Districtprovided toyou by theDistrictYouth ExchangeCommittee.
9) The student mustreturn homedirectly by a route mutually agreeabletotheHost Districtand student’s parents.
10) The studentshallhavesufficientfinancialsupport toassurehis/herwell-being during the exchange. Any unusualcostsrelativetoa student’s early return homeorotherunusualcostsshallbetheresponsibil- ity of the student’sown parents/guardians.
11) YouwillbeundertheHosting District’sauthority whileyouarean exchangestudent. Parents/guard- iansmustavoid authorizingany extra activities directly totheirson/daughter. TheHostCluband DistrictYouth Exchangeofficersmustauthorize such activities. Relativesin thehostcountrywillhaveno authorityoverthe studentwhilethey arein the program.
PermissionforMedicalCareandRelease ofLiability
In consideration of theacceptanceand participation of theapplicantin such program, theundersignedAPPLICANT andhisor herPARENTSorLegal GUARDIANS, tothefullextentpermitted by law, hereby releaseand agreetosave, hold harmlessand indemnify, allhostparentsand membersof theirfamilies, and allmembers, officers, directors, committeemembersand employeesof hostand sponsoring Rotary Clubsand Districts, and of Rotary International,fromany orall liability foranyloss, property damage, personalinjury ordeath, including any such liability which may ariseoutof thenegligenceof any such personsorentities, which maybe suffered orclaimed by such applicant, parentorguardian during, orasa resultof, the participation by theapplicantin suchYouth Exchangeprogram, includingtraveltoand from thehostcountry.
We, theparents/guardiansof theapplicant, andtheapplicantif of legalage, whohavethesoleand legalright tomakethe decisionson thehealth and careof theapplicantdo release from liabilityand grantpermissionasnoted of thefollowing whileourson/daughter/ward isoverseasasa Rotary Youth Exchange student:
● In the eventof accidentor sicknesswe/Iauthorizeany Rotarian, authorized chaperonesof Rotary activitiesand host parent(s) of ourson/daughter/wardto selectthe appropriate medical facility andphysician(s)/dentist(s)to provide treatment;
● We/Igivepermission forany operation,administration of anesthetic orblood transfusion which a medicalpractitioner may deemnecessary oradvisableforthetreatmentof ourson/daughter/ward;
● We/Ifurtherconsent to anymedical orsurgical treatment bya licensed physician, surgeon ordentistwhich might be required by ourson/daughter/ward for any emergencysituation.Wedorequestthatwebenotified assoon aspossible, butemergency treatmentneed not bedelayed to providesuch notice. Permission isgranted forimmunizationsrequired forschoolregistration;
● In thecaseof electivesurgery,we/I requestthatwe/I benotifiedpriortosuch arrangements.
Having read and understood the“ProgramRulesand Conditionsof Exchange,”weagreetoabideby these rulesand condi- tionsand understand thatany violation may resultin abrupt termination of the exchange, andwefurtheragreethat thehost Rotary clubandhostRotary districtshallhavefinalauthority in enforcing theserulesand conditionsand anyother rulesand conditionswhich maybeimposed with duenotice.
In thepresenceof SponsorRotary ClubRepresentative * ______
(Signature)
Dated this Day of
(Month)(Year)
Emergency Contact in home country
NameRelationtoyou
TelephoneFax
SupplementalInformation
SPONSORINGDISTRICTANDCLUBCONTACTS
DistrictChairperson: Scott White
Name
Denver Machine Shop; 9762 Hanover Court East, Henderson, CO 80640
Address
303 295 6000303 295
TelephoneFaxE-mail
ClubRepresentative:
(OfficerorYEO)Name
Address
Telephone / Fax / E-mailSTUDENT
Familyname/Legalname / First/Given name / Second/Given name / Sex(M/F)
Dateyoupreparedanswers(yr/mo/day) / Religion(spellout) / DietaryRestrictions (If“ / YES,” explain)
1. Pleaselist thelanguagesyouhavestudied and indicateyourlevelof fluency. (1 =Poor, 2 =Marginal, 3 =Short Sentences, 4 =Fluent)
1stLanguage / 1 / 2 / 3 / 42nd Language / 1 / 2 / 3 / 4
3rd Language / 1 / 2 / 3 / 4
2. Whatisyourfavorite schoolsubject? Why?
3. Whatareyourinterestsand activities? Whatleadership positionshaveyouheld (in schooland outsideactivitiessuch as scouting)?
4. Whatareyourhobbiesand accomplishments? Elaborateon yourinterestsin theseareas(e.g.,Why did you become interested in theactivity? How long haveyou been interested? How much timedoyoudevotetotheactivity?).
5. Whatareyourfutureplansand ambitions?
6. Why doyouwish to participatein thisprogram?
7. MostRotaryClubs/Districtsrequireyou tohostthe studentwith whomyouwillbe staying whileon thisprogram.
Isyourfamily willing tohostan inbound exchange studentin yourhome?YesNo
Whatdoyoupreferasthegenderof thestudentyouwillhost? (Pleasecheck one)MaleFemale Either
8. Describeyourcommunity andhome.
9. Describeyourfamily interests, activities, pets, siblingsathome, etc.
10. Identify fourmajorissuesconfronting youth today. Select themost majorissueand telluswhy itisof personalconcern.
11. MedicalInformation
a. Doyouhaveany medicalconditions? Pleasedescribe.
b. Haveyou taken any prescribed medicationsin thepriorsixmonths? Pleaseprovidethenameof themedication and reason itwasprescribed.
c. Doyouhaveany specialhealth considerations(allergies, disabilities, etc.)? Pleasedescribe.
12. ** Doyousmoke?YesNo ** Haveyoueverbeen involved with illegaldrugs?YesNo
** Doyoudrink alcoholic beverages?YesNo
**If youanswered “YES” toany of thequestionsasterisked, pleaseexplain: (see Instructions, insidecoverpage)
PicturePage
Onceyouhaveyourfourpictures, show them totheRotarian orteacherassisting you. If thepicturesareapproved forthe purposehere, affixthepicturestothepagewith glueordouble-sided tape(donotstaple).
MyHome MyFamily
MySpecialInterest SomethingImportanttoMe