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© 2018 Interact 5495

ROTARY DISTRICT 5495 SHORT-TERM YOUTH EXCHANGE PROGRAM

 

STUDENT APPLICATION

 

For AZ Interact Ambassadors to Kenya Trip, June 29 – July 15, 2018

Please copy and paste this application form in a separate document to be filled out and emailed to MLazere@azdes.gov and arthts@msn.com

 

 

Student Last Name _____________________________ First Name _______________________________

Mailing Address _________________________________________________________________________

Street Address if different_________________________________________________________________

City/State ________________________________________________Zip Code ______________________

Home Phone _____________________ Cell _____________________Email ________________________

Date of Birth _____________ Age________ Sex (M / F) Religion_________________________________

Do you have any dietary restrictions? Explain________________________________________________

Do you require any medication or have any medical condition we should be aware of?

Explain ________________________________________________________________________________

Do you smoke? (Y / N) Do you drink alcoholic beverages? (Y / N)

Have you ever used drugs? (Y / N) Have you ever been arrested? (Y / N)

How much time do you devote to studying away from school? __________________________________

Name of High School ___________________________________________ Current grade level ________

GPA: ___________ Approximate Class ranking ________ Active Member of Interact Club? (Y / N)

What languages have you studied and for how long? If program such as Rosetta Stone, level attained:

_______________________________________. _ __________________ .

 

Parents or Legal Guardians:

Father’s name _____________________________Mother’s Name _______________________________

Address__________________________________ Address _____________________________________

Home Phone ______________________________ Home Phone _________________________________

Cell ______________________________________ Cell _______________________________________

Email Address _____________________________Email Address _______________________________

Occupation __________________ Rotarian (Y / N) Occupation ___________________ Rotarian (Y / N)

 

 

Names of brothers/sisters and ages

_________________________________________________________________________

 

Student signature ____________________________________ Date _________________

Parent signature _____________________________________ Date _________________

Tell us some of your interests (school clubs such as Interact Club, RYLA attendee, sports, leadership roles,

scouting, hobbies inside or outside of school, volunteering, community service) and how much time you devote

to them:

 

Tell us about your travel experiences away from home with and/or without your family:

 

Tell us about your family (what do your parents do, how long have you lived in the area, what do your siblings

do, other):

 

Tell us why Rotary should consider you a potential “Ambassador” for Interact, Rotary and your country?

(Achievements, awards, talents, interests, etc.):

 

Is your family willing to host a school year Rotary foreign exchange student for 3 ½ months? (Y / N)

Is there any other information you would like to share with us?

 

Please forward at least one letter of recommendation to:

Dr. Art Harrington, District Youth Services Chair

802 Oak Terrace Drive

Prescott, AZ 86301

(928) 245-0411

Fax: (928) 756-2447

Email: arthts@msn.com

 

Note: Applications are due by January 15, 2017. The applications will be screened by the Rotary Youth Exchange Committee, and applicants will be contacted about scheduling an online interview with members of that committee. The five Interact representatives will be selected by February 1, 2018, and will be presented at the Interact District Conference on February 24, 2018, at Perry High School in Cottonwood.