Rotary District 6540

Central States Rotary Youth Exchange Program, Inc.


If no change, please indicate!

General Information

Month for Report (Required)
Student's Name (Required)
Student's E-mail (Required)
Hosted By Rotary Club of (Required)
Youth Exchange Officer's Name
Present Host Family's Name (Required)
Street Address
Home Phone
Business Phone
Host Mother's First Name
Host Father's First Name
Date of anticipated move to next host family (MM/DD/YYYY)

Activities since last report

Tell us about your activities, such as public speaking engagements, social activities, places of interest you visited, contact with other exchange students and community projects and any newspaper, radio, or television interviews. Include any comments, suggestions, requests, complaints, or impressions you may wish to share with us.

What subjects are being studied at school? (If no change, so indicate).

How is your language proficiency progressing?

Rotary activities since last report

Number of Rotary club meeting attended
Have you attended any Rotary Youth Exchange meetings or conferences? Yes No
Are you receiving your monthly allowance regularly? Yes No
Amount $
Are you helping your Rotary club with a community service project? Yes No

(If yes, please write details of the project and your involvement below)

Has contact been made between your host Rotary club and sponsoring club? (i.e., letters, tapes, photographs, bulletins, etc.) Yes No

Are you corresponding regularly with:

Your family at home? Yes No
Your sponsoring Rotary club? Yes No

How is your relationship with:

Your host family?
You host Rotary club?
Your school?
You fellow students?
Your youth exchange officer?
Have you met with your youth exchange office or counselor this month? Yes No

The following section of this report will be kept confidential if you wish Yes No

If you are having difficulties or problems, please tell us about them. Please tell us about the good times as well. Include any comments, suggestions, requests, complaints, or impressions you may wish to share with us.

If you are reporting a problem, is it important that we help you at this time? Yes No
If you have moved to your new family, did you complete the change form at Yes No