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Online Expression of Interest
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Please read the RULES FOR OUTBOUND EXCHANGE STUDENTS
before completing this application form.

Please fill in all fields.
Type "na" for fields that are not applicable.

 
 

Please read the RULES FOR OUTBOUND EXCHANGE STUDENTS before completing this application form.

Please fill in all fields. Type "na" for fields that are not applicable.

Please Note: Applicants MUST attend the following functions:

  1. District Interviews - mid May 2012 (date to be advised)

  2. First Briefing Day - late August 2012 (date to be advised)

  3. Final Briefing Day - early December 2012 (date to be advised)

Please do not apply if you are unable to attend these compulsory functions.

Privacy Statement Directed to Scholarship Applicants
and their Families or Guardians
   
To the Rotary Club of:
 
PERSONAL DETAILS
First Name:
Middle Name:
Family Name:
Preferred Name:
 
Postal Address:
Suburb:
State:
Post Code:
Residential Address:
(If different from above)
 
Home Phone:
Mobile:
Email:
 
Sex: Male Female
Date of Birth:
Are you an Australian Citizen? Yes No
 
Father's First Name:
Father's Family Name:
Mother's First Name:
Mother's Family Name:
 
 
SCHOOL INFORMATION
At present I am in Year: at
Current Studies:
(Please list all subjects and Year level)
 
  Language Written Verbal  
Foreign Languages Studied:
(Please give details of any languages Studied and level of fluency)		  
 
 
 
School and community Awards, Leadership, Musical interests, etc:
Sport and leisure activities:
When I complete my schooling I plan to:
 

I believe my educational qualifications meet the criteria for selection:

Yes No

I will be able to show you my past year's school reports.
You may also make further enquiries of the School Principal if you wish.

Yes No

 
My reasons for applying to go overseas for 12 months with Rotary:
I will also produce character references from:  1.
 2.
Any other relevant information not covered above:
 
 
HEALTH
Please list any Health conditions:
(e.g. Asthma)
Please list any dietary restrictions:
 
 
DESIRED COUNTRY FOR EXCHANGE
Please select 4 countries from the list below in order of preference and briefly outline reasons for interest
1.
2.
3.
4.
The district Committee will endeavour to allocate one of the above four choices.

If you would prefer not to exchange with any particular country region,
please select them below and briefly outline the reason for concern
1.
2.
3.
 
How did you become aware of the Rotary Youth Exchange Programme? Other:
 

I would like to participate in the Rotary Youth Exchange Programme.
I have read and understand the rules and my responsibilities should I be selected

Yes No
This Expression of Interest will be automatically forwarded to District 9520 Rotary Youth Exchange Committee.
The completed form will be sent to your Email address.
Rotary District 9520

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