EmailMe Form - D5000 Rotary Youth Exchange Pre-app

Student's name *
First Last
Name You Prefer To Be Called
City or Town of Residence *
Island student lives on *
Birthday *
MM / DD / YY
Attending High School *
Current year in High School *
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 *