Initial Interest Form - Rotary International District 7470 Youth Exchange Program - Northern New Jersey

Please Complete the Following Form

Please fill out this form if you live in Essex, Morris, Sussex and Warren counties and Bernardsville and Basking Ridge in Somerset County, New Jersey, USA, are in High School and may be interested in studying overseas. When you complete this form and press submit. You will receive an application for the Rotary District 7470 Youth Exchange Program. If you are from another New Jersey Rotary district your information will be sent to that district and they will contact you.

This application is to indicate interest in the program and does not commit you to becoming a student in the program.

Fields marked with a red asterisk (*) are required.
*I am Interested in the...
*Your name:
*Gender:
*Date of Birth:
*Country of Citizenship:
*Your Email Address:

*Street Address:
*City/Town:
*State:
*Zip Code:
*Home Phone Number:
Fax Number:

*Name of School:
*This year I am
*Primary Foreign Language Known:
*Proficiency in Primary Foreign Language:
Secondary Foreign Language Known:
Proficiency in Secondary Foreign Language:
Extracurricular Activities, Interests & Hobbies:

Reasons you wish to become an exchange student:
What do you hope to accomplish during and after your exchange?

*Parents name and address:
*Do your parents support you in your quest to become an exchange student?
Father's Occupation:
Mother's Occupation:
Please List the Names and Ages of your brothers and sisters:

As part of being an Exchange Student, your family is expectedto be a host for an Exchange Student If you are unable to host, please list families who may be willing to host an Exchange Student.
*My family can host a student...
List names, addresses, and phone numbers of any other families that might be interested in hosting a student:

Other information: