Rotary District 5630 Youth Exchange Preliminary Application Form

Transcription

1 Rotary District 5630 Youth Exchange Preliminary Application Form Please submit 1 original and 3 copies of this application to Paula Witt 614 W 10 th Street, Hastings, NE no later than October 15, 2016 LATE APPLICATIONS WILL NOT BE ACCEPTED After this preliminary application is received, your local Rotary club will arrange and conduct interviews for students and parents. Those clubs will determine which applicants advance to mandatory District interviews in North Platte. Both students and parents will be interviewed November 12, The students chosen to receive a Rotary Study Abroad Scholarship will then complete an extended Rotary International Application due by mid-january, 2017 and depart for their respective countries in late July-August Date: Long-term exchange program from District 5630 (Term: months, Age: 15-18½ years, Fee: $5,500) Full Name: Address: City: State: Zip: Phone(s): Your Date of Birth: Father s Name: Phone(s): Occupation: Rotarian Yes No Club Name Address: City: State: Zip: Father s Mother s Name: Phone(s): Occupation: Rotarian Yes No Club Name Address: City: State: Zip: Mother s Are your parents divorced? Rotarian Yes No What is your living situation? School: When will you graduate? Sophomore Junior Senior Rank in class: Upper 1/3 Middle 1/3 Lower 1/3 What is your GPA? Time spent on homework daily Language(s) studied, number of years Have you traveled internationally before? Yes No If so, where? Do you ever smoke? Yes No Do you ever drink alcohol? Yes No Have you ever used drugs? Yes No Steady boy/girl friend? Yes No Are you a Vegetarian? Yes No Are you a Vegan? Yes No Are you receiving any medical treatment? Yes No Do you have allergies? Yes No Identify allergen and symptoms/management.

2 Describe the status of your health (list any allergies or medications you take regularly) Are you being, or have been treated for ADHD, depression or mental illness? Yes No Eating Disorder? Yes No Please explain: Are you receiving any medical treatment now? Yes No Please explain: If selected, I agree to the rules of the program and accept the supervision of the host District, host club and host family. I agree to correspond with my District counselor and sponsoring club on a regular basis. I agree to accept speaking engagements at Rotary and other community functions during and after the period of the exchange. When I return home, I agree to return by the closest and quickest route agreed upon by the host club, the District, and my parents. Signed Date: (Student Applicant) Signed Date: (Parent/Guardian) Mother Signed Date: (Parent/Guardian) Father

3 FOR STUDENT APPLICANT Please provide the following information: Do you have a passport? Yes No Country Issuing Passport Date of expiration Please List Your Siblings (name, age, gender, living at home): Why should you be selected for a Rotary International Youth Exchange Scholarship (valued at $13,000 to $51,000)? Why are you interested in a Rotary sponsored exchange instead of a different exchange programs available to high school students? What do you think are your responsibilities as a Rotary Exchange Student? How do you plan to fund your exchange (fees and expenses during your year abroad)? What do you hope to accomplish during and after your exchange?

4 How do you think your life will change as a result of being abroad for an extended period of time? How will your family be affected by your absence for a year? What do you think are the major issues confronting the world today? What are your interests and/or hobbies? What classes particularly interest you and why? What leadership positions have you held in school, church, clubs or organizations?

5 What do you do in your free time? What are your future plans and ambitions? Describe your relationship with each of your family members. Do you or your family have any travel plans or other major events in the summer of 2017? Yes No If yes, please list the dates and describe the travel plans. Is your family willing to host an inbound student if you are selected to be an exchange student? Yes No (This is encouraged for all families of Rotary Youth Exchange students, but not required.) You are encouraged to promote Rotary Youth Exchange to others in your community and schools. Please list the names of 3 families (one a 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.

6 Rotary District 5630 Youth Exchange Scholarship Preliminary Application (continued) 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

7 Rotary District 5630 Youth Exchange Scholarship Preliminary Application (continued) Student s Name: Reasons I do not wish to be an exchange student in these countries:

8 Rotary District Long-Term Exchange Program Section G: Secondary School Personal Reference Student: Complete the top section of this form, then give the form and a stamped envelope, preaddressed to the Rotary club or district to which you are submitting your application, to a teacher or administrator who knows you and your abilities and accomplishments at school. By so doing, you give permission to that individual to release this information to the Rotary club/district Youth Exchange committee for their review. Applicant s Full Legal Name Date of Birth Home Address Street City State/Province Postal Code Country Male Female Address Home Phone Number Mobile Phone Number Evaluator: This student is applying for a one-year educational study abroad program under Rotary club/district sponsorship. Please complete and forward this form within seven days of receipt in the preaddressed envelope provided. The information you submit will not be revealed to the student, unless required by law. 1. Ratings Area Excellent Good Average Below Average No Basis to Rate Creative, original thought Independence, initiative Intellectual ability Emotional stability Academic achievement Openness to new ideas Flexibility, adaptability Ability to communicate Potential for growth Disciplined habits Participation 2. Do you believe the applicant has the ability, work habits, character traits, and flexibility to succeed in an unfamiliar environment that will include learning a foreign language? Yes No 3. Do you believe the applicant s parents/legal guardians support his/her wish to spend time abroad? Yes No Not Sure Please use the reverse side of this form to explain your answers to questions 2 and 3, and add any additional comments on the applicant s suitability as an exchange student and cultural ambassador. RECOMMENDATION I recommend this student as a future Rotary Youth Exchange student (check one): Strongly Recommend Recommend No Opinion Do Not Recommend Strongly Do Not Recommend Name and Title (type or print) Signature (in blue ink) Date (e.g., 01/Jan/2006) Name of School Phone DO NOT RETURN THIS FORM TO THE STUDENT. Rotary Youth Exchange Program: Personal Reference Section G, Page 1 of 1