Rotary District 5630 Youth Exchange Scholarship Preliminary Application Form

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1 Rotary District 5630 Youth Exchange Scholarship Preliminary Application Form Please submit one (1) original and three (3) copies of this application to Rotary District 5630 Youth Exchange Officer Paula Witt, 614 W 10th St., Hastings, NE no later than October 15, LATE APPLICATIONS WILL NOT BE ACCEPTED. After this Preliminary Application is received, your local Rotary club will conduct interviews of students and their parents. Those clubs will determine which applicants advance to mandatory District interviews. Both students and parents will be interviewed in North Platte, Nebraska on Saturday, November 14, Students awarded a Rotary Study Abroad Scholarship will then complete an extended application by mid-january 2016 and will depart for their respective countries in late July or August, By signing below, I affirm that all of the information in this application is true and correct. If selected, I agree to follow the rules of the RYE program and accept the supervision of the sponsoring Rotary District, hosting District, host club and host family. Student Name: (please print) Student Signature: Date: Parent(s) Name (s): (please print) Parent Signature : Date: Parent Signature : Date: 1

2 District 5630 Youth Exchange Scholarship Preliminary Application for the Academic Year (Academic Year Term: months, Age: years; Fee: $5,500) Student s Full Name: Address: City: State: Zip: Home Phone: Cell Phone: Student s Date of Birth (DD/MM/YYYY): Father s Name: Occupation: Address: City: State: Zip: Home Phone: Cell Phone: Father s Mother s Name: Phone(s): Occupation: Address: City: State: Zip: Home Phone: Cell Phone: Mother s 2

3 Student s Name: Age: High School: Year in school now: Freshman Sophomore Junior Senior Expected graduation date (MM/YYYY)? Rank in class: Upper 1/3 Middle 1/3 Lower 1/3 How much time do you spend on homework daily? Language(s) studied: Have you traveled internationally before? Yes No If so, where and for how long? Do you smoke or use any tobacco products? Yes No Do you drink alcohol? Yes No Have you ever used drugs? Yes No Do you have a steady boy or girl friend or serious dating relationship? Yes No Are you a vegetarian? Yes No Are you a Vegan? Yes No Describe the status of your health. List any medications you take regularly Are you being or have you been treated for an eating disorder? Yes No If yes, please explain treatment and when treatment occurred Have you ever been treated for ADHD, depression or mental illness? Yes No If yes, please explain treatment and when treatment occurred Are you receiving any medical treatment now? Yes No If yes, please explain please explain treatment and when treatment occurred Do you have allergies? Yes No Identify allergen 3

4 Student s Name: What are your interests and hobbies? What are your favorite subjects in school? What are your least favorite subjects? Why should you be selected for a Rotary International Youth Exchange Scholarship (valued at $13,000-$51,000)? Why are you interested in a Rotary Youth Exchange Scholarship vs. other exchange programs available to high school students? What do you believe are your responsibilities as a Rotary International Scholarship ambassador? How would a Rotary Study Abroad Scholarship affect your life and future goals? How do you plan to fund your year abroad? What do you believe are some of the major issues confronting our world today? 4

5 Student s Name: Describe your relationship with each of your family members. Do you or your family have any travel plans or other major events this coming summer which may conflict with preparations and outbound training in May or June, 2016? Yes No If yes, please list the dates and describe the travel plans. _ Is your family interested in hosting an inbound student in your home this year or sometime in the near future? Yes No (This is encouraged for all families of Rotary exchange students but not required.) You are encouraged to promote Rotary Youth Exchange to others in your community. Please list the names of three families (at least one Rotarian family) with whom you have discussed Rotary Youth Exchange and who MAY be willing to be a host family for an inbound exchange student in the future Questions? Visit and or call Paula Witt at or her at Please attach the original and three (3) copies of letters of recommendation from two (2) individuals (not family members). The Secondary School Personal Reference form (see Page 8 below) must also be submitted in an unopened sealed envelope or mailed BEFORE October 15, 2015 to: Paula Witt District 5630 RYE Chair 614 W 10th St. Hastings, NE or ed to 5

6 Student s Name: Rotary Youth Exchange Certified Countries This is a list of countries with districts certified to participate in Rotary Youth Exchange. We do not exchange with other English-speaking countries. This list is subject to change. Some countries may accept students who have already graduated from high school. PLACEMENT IN COUNTRIES OF PREFERENCE CANNOT BE GUARANTEED. * Indicates countries which require personal appearance at the country s consulate (usually in New York, Washington, DC, Chicago, San Francisco, etc.) for a personal interview in order to receive a visa. Consulate visits are not included in the RYE fee. FAMILIES SHOULD BUDGET FOR A CONSULATE VISIT, REGARDLESS OF THE COUNTRY OF PREFERENCE. Please mark ten (10) countries in order of preference (1-10). Please mark an X by five (5) countries which you absolutely would NOT want to go and state your reason(s) on the next page. Argentina Australia Austria Belgium Brazil Bosnia Bulgaria Chile* Colombia Croatia Czech Republic Denmark Egypt Estonia Finland* France* Germany Greece Greenland Hungary Iceland India Indonesia Israel Italy* Japan Kyrgyzstan Malaysia Mayotte Mexico* Namibia Netherlands Nigeria Norway Paraguay Peru Philippines Poland Portugal Reunion Island Romania Russia Scotland Singapore Slovakia Slovenia South Korea Spain Sweden Switzerland Taiwan Thailand Turkey Venezuela 6

7 Student s Name: Reasons I do not wish to be an exchange student in these countries: 1._ 2._ 3._ 4._ 5. _ 7

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