Rotary District 3060 Youth Exchange

Rotary District 3060 Youth Exchange

Local Application Form (2 Pages)

Please submit 1 original and 1 copy of this application to your local Rotary Club (Also send scan copy of application to IYE Chairman Rtn. Devang Mumim. The Rotary Club must forward the application no later than October 15, 2016 to the IYE team members notified below. Your local Rotary club may arrange and conduct interviews for students. Clubs will recommend which applicants will advance to District interviews to be held on a date and place which will be intimated later. Interviews will be held shortly after close of application receiving date. The students chosen for the program will depart for their respective countries the following summer in late July-August for long-term or May-July for short term. For NGE departure are decided later.

Sponsor Rotary Club / Exchange Applied For Long-Term/ Short-Term/NGE
Full Name of student (as per Passport) / Date of Birth
Address / City, State and Pin code
Residence Phone / Student's Cell Phone
Student's Email
Parent's Name / Parent's Cell Phone
Parent's Occupation / Parent's Email
School Name / Class Studying In
Medium of Instruction in School / Rank in Class
Prior International Travel (Mention Countries Visited) / Are you a Rotarian’s son/daughter?

Describe the status of your health. Are you receiving any medical treatment? ______

______

______

If selected, I agree to the rules of the program and accept the supervision of the host District, host club and host family.

Signed ______Date ______

(Student Applicant)

Signed ______Date ______

(Parent/Guardian)

Please provide the following information:

Why do you want to become an International Exchange Student?

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List your major academic and extra-curricular achievements and awards: ______

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What do you think your responsibilities are as a Foreign Exchange Student?

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What do you hope to accomplish during and after your exchange?

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What do you think are the major issues confronting the world today?

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What are your future plans and ambitions?

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List, in order of preference, 5 countries in which you would like to be an exchange student.

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Attachments:

1.  Letter of recommendation from a school teacher and latest school mark-sheet/report.

2.  Club’s Board Resolution as per attached format.

3.  Please attach Demand Draft of Rs. 5,000/- drawn in favour of “RI District 306 Trust account IYE”---payable at Valsad (Bulsar)

Note: Please submit your application to the following as per your convenience.

IYE Chairman

a) Rtn. Devang Munim

Chairman IYE, Year 2016-2017

C/O Pooja Agencies

Plot no2/860 Pooja House

Ring Road, Surat – 395002

Mob. 9824129547

Email Id:

Long Term Chairman

b) Rtn. Dr. Mrugank Merchant

Long Term IYE Chairman, year 2016-2017

49, Haribhakti Colony, Race Course,

O.P.Road, Vadodara – 390001

Mob. No. 9825094737

E-Mail Id.

Short Term Chairman

Rtn. Dharmesh Chorawala

Short Term IYE Chairman, Year 2016 – 2017

Opp. Manan Bungalow, Nr. DRB College,

New City Light Road, Surat – 395007

Mob No. 9825289399

E-Mail Id:

NGSE Chairman

Rtn. Nimish Gosalia

NGE IYE Chairman, year 2016-2017

C-9, Jnanta Nager Society,

Behiend Rutu Raj Complex,

Near Vatika Bunglows,Vasna Road,

Baroda - 390007.( Guj) India

Mob No :- 09375646739

E-Mail Id :

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