Preliminary Outbound
Youth Exchange Student Application
Milton
Rotary Club
Application
deadline: Friday, February 16, 2007
❑ Long-Term Program
❑ Short-Term Program
Yes, I am interested in representing my country as an exchange
student!
____________________________________________________________________________
Full Name
____________________________________________________________________________
Street Address
____________________________________________________________________________
City State Zip
Code
____________________________________________________________________________
Telephone E-mail (please
print clearly)
____________________________________________________________________________
Date of birth Year in school
Your interests, activities, and
hobbies:
___________________________________________________
____________________________________________________________________________
Your extracurricular activities
at school: __________________________________________________
____________________________________________________________________________
Non-native languages you have
studied (with number of years studied):
______________________________
____________________________________________________________________________
Your past travel experiences:_________________________________________________________
____________________________________________________________________________
Reasons you wish to become an
exchange student:___________________________________________
____________________________________________________________________________
What do you hope to accomplish
during and after your exchange?
_________________________________
____________________________________________________________________________
Do
your parents support your desire to become an exchange student? ❑ Yes ❑ Unsure
❑ No
____________________________________________________________________________
Applicant’s Signature
____________________________________________________________________________
Parents’ and/or Legal
Guardians’ Signatures
Please
return this application to:
Dr. John Drottar, Youth Exchange Chairman, Milton Rotary Club
12 Desmond Road
Randolph, MA 02368
Further
questions? Contact Dr. Drottar at (617) 696-4470 extension 5503