Prelim Application for Rotary Youth Exchange

Preliminary Outbound Student Application

Thank you for your interest in District 5400 Rotary Youth Exchange! This preliminary application is the first step in the selection process for studying abroad during the during the 2026-2027 school year. Your responses will be shared only with Rotary volunteers who are involved with the selection of outbound students. You should complete this application by September 30; however, some clubs might have a later deadline. It's best to submit it earlier to make sure you are considered. Questions? Contact your local Rotary club, or our District 5400 leaders at YouthExchange5400@gmail.com.
Which program are you interested in? (select all that apply)*

Long-term Exchange (full school year)Short-term Exchange (summer break)I'm not sure; I want to learn moreOther
Student Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender
Current High School, City
ex: Century HS, Pocatello
Grade level this fall
ex: 10th, 11th, or 12th
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Student E-mail*
Student Mobile Number

Area CodePhone Number
Student Home Number

Area CodePhone Number
Mother's Name

First NameMiddle NameLast Name
Father's Name

First NameMiddle NameLast Name
Mother's E-mail
example@example.com
Father's E-mail
example@example.com
Mother's Number

Area CodePhone Number
Father's Number

Area CodePhone Number
Please share a portrait photo of yourself (a school portrait or a passport photo). *

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Preliminary Outbound Student Application