Youth Exchange Travel Request
Please complete this travel request BEFORE committing to any travel outside of Rotary Dist. 6510. This includes travel with your host family or any other groups. This request must be approved by Steve Jackson or Judy Berowski before your trip.
Exchange Student Name *
Your answer
Student's Email *
Your answer
Student's Cell Phone *
Your answer
Student's Host Rotary Club *
Rotary Club of_____
Your answer
Current Host Family *
First and Last Name of a Host Parent
Your answer
Host Family email *
best email contact for current host family
Your answer
Studnent's Home Country *
Your answer
Host Family Cell Phone *
Best Cell contact to reach during requested travel
Your answer
Travel Destination *
Please include all overnight stop locations during your trip
Your answer
How are you traveling *
plane, train, car, other?
Your answer
Whom are your traveling with? *
Please include the responsible adult and drivers.
Your answer
Name of responsible adult during trip *
First and Last Name
Your answer
Phone Number of Responsible adult during travel *
Your answer
Where will you be staying when you arrive. *
Include the address and phone number of the facility of host home.
Your answer
Requested Dates or travelt *
Please include dates you will leave and return
Your answer
Who from your Host Rotary Club have you discussed this trip request? *
If you have not yet please indicate who you will speak with and when.
Your answer
By typing my name below I acknowledge this is a request for travel. I WILL NOT LEAVE THE DISTRICT WITHOUT APPROVAL FROM STEVE JACKSON OR JUDY BEROWSKI." *
Please type your full name below.
Your answer
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