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D5000 Rotary Youth Exchange Pre-app
Please complete the follow form to assist us in opening the discussion about a year abroad.
Student's name
*
First
Last
Name You Prefer To Be Called
City or Town of Residence
*
Island student lives on
*
Please select
Oahu
Maui
Kauai
Big Island
Birthday
*
MM
/
DD
/
YY
Attending High School
*
Current year in High School
*
Please select
Freshman
Sophomore
Junior
Senior
Student's Cell Phone
*
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-
###
-
####
Student's Email
*
Does the Student have a valid US passport with at least 2 years left before expiration?
*
Yes
No
In Process Now
Yes with a different country(state country below)
Langauges spoken other than English
*
5 Countries You Would Like To Be Placed
Any Country You Would NOT Like To Be Placed
Primary Parent or Guardian's Name
*
First
Last
Primary Parent or Guardian's Email
*
Primary Parent or Guardian's Cell Phone
*
###
-
###
-
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Relationship with student
*
Please select
Mother
Father
Guardian family member
Other (state in comment below)
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