EmailMe Form - Youth Exchange Report

Month and Year *

MM / YY

Your Name *

Your email address *

Host Club

Club and Counsellor Details

Host Club

Host District

Host Counsellor

Host Counsellor Address

Host Counsellor Telephone (AH)

Host Counsellor Telephone (BH)

Host Counsellor Fax

Sponsor Club

Club and Counsellor Details

Sponsor Club

Sponsor Club Counsellor

Sponsor Club Counsellor Address

Sponsor Club Counsellor Telephone (AH)

Sponsor Club Counsellor Telephone (BH)

Sponsor Club Counsellor Fax

Host Family

Host Family and Contact Details

Present Host Family Name

Present Host Family Address

Present Host Family Telephone (AH)

Next Host Family Name

Next Host Family Address

Next Host Family Telephone (AH)

Date of expected change

DD / MM / YYYY

Until

DD / MM / YYYY

Have you?

Have you done these things since your last report?

Have you contacted your parents?

Yes

No

Have you contacted your host club counsellor?

Yes

No

Have you contacted your sponsor club?

Yes

No

Have you experienced any difficulty with your host family?

Yes

No

Family Comments

Have you contacted your experienced any difficulty with your host club?

Yes

No

Host Club Comments

Have you experienced any difficulty with your school?

Yes

No

School Comments

Have you tried to resolve these difficulties?

Yes

No

Difficulty Resolution Comments

Have you attended a meeting of you Host Club?

Yes

No

Club Meeting Comments

Have you attended another Rotary Club Meetings?

Yes

No

Have you performed any public speaking engagements?

Have you participated in any non Rotary Activities?

Have you had any illness or injury?

Can the District 9790 Committee do anything to assist your exchange?

Travel since last report?

Next Travel?

Additional Comments?