Family Application Rotary Club*AuroraAurora GatewayBoulderBoulder ValleyBreckenridgeBroomfield CrossingBrushCentennialCommerce CityConiferDenver Club 31Denver SoutheastEvergreenFort MorganGatewayGoldenGrandbyHighlands RanchLittletonLongmontNglenn/ThorntonNiwotParkerSummit CountyTwin PeaksWinter Park/FraserCastle Rock MorningRotarian/Youth Exchange Officer full name* YEO Email address* A copy of this application will be emailed to this email. HiddenCountry of the potential student? If known, please list the student. If you do not know, please indicate ‘unknown’ or ‘tbd’.Country of the potential student*ArgentinaAustriaBelgiumBrazilCroatiaCzech Republic / SlovakiaDenmarkEcuadorFinlandFranceGermanyItalyPeruPhilippinesSpainSwedenSwitzerlandTaiwanTBDIf unknown & this is for the next school year, please indicate “TBD”Anticipated move in date* MM slash DD slash YYYY If for the next school year, please indicate 8/15/20YY YY= the year the student would arrive. Please enter the name and contact information for all household members over 18. This includes family members under 18 now who will be over 18 during the exchange year. A college student who only visits occasionally still needs to be included. If there is any doubt, please err on the side of caution and request they sign the application and complete the background check. All fields for all family members should be complete.First name* Middle* Last* Gender* Birth Date (MM/DD/YYYY)* MM slash DD slash YYYY Marital Status* Street Address* HiddenStreet AddressCity* State* Zip Code* Email* Home Phone*Business Phone*Cell Phone*Occupation* Family Member over the age of 18 #2 (FM2)First Name Middle Name Last Name Gender Birth Date (MM/DD/YYYY) MM slash DD slash YYYY Marital Status Street Address City State Zip Code Email Home PhoneBusiness PhoneCell PhoneOccupation Family Member over the age of 18 #3 (FM3)First Name Middle Name Last Name Gender Birth Date (MM/DD/YYYY) MM slash DD slash YYYY Marital Status Street Address City State Zip Code Email Home PhoneBusiness PhoneCell PhoneOccupation Family Member over the age of 18 #4 (FM4)First Name Middle Name Last Name Gender Birth Date (MM/DD/YYYY) MM slash DD slash YYYY Marital Status Street Address City State Zip Code Email Home PhoneBusiness PhoneCell PhoneOccupation HiddenPart 2 – Host Family Members under the age of 18:Please list the full name and relationship of persons living full-time or part-time in the home or who frequently stay at the home, who are under 18. Relationship ex: son,daughter, niece, etc.HiddenIf no children in the home check this box HiddenName 1 HiddenDOB 1 HiddenRelationship 1 HiddenEducation 1 HiddenHobbies 1 HiddenName 2 HiddenDOB 2 HiddenRelationship 2 HiddenEducation 2 HiddenHobbies 2 HiddenName 3 HiddenDOB 3 HiddenRelationship 3 HiddenEducation 3 HiddenHobbies 3 HiddenName 4 HiddenDOB 4 HiddenRelationship 4 HiddenEducation 4 HiddenHobbies 4 HiddenName 5 HiddenDOB 5 HiddenRelationship 5 HiddenEducation 5 HiddenHobbies 5 HiddenPart 3 – Personal References:At least three references must be contacted and one references contacted must be an immediate relative. HiddenPersons that are not relatives or former employers that we may contact. HiddenName HiddenOccupation HiddenTelephone HiddenName 2 HiddenOccupation 2 HiddenTelephone 2 HiddenName 3 HiddenOccupation 3 HiddenTelephone 3 Immediate Relative over 18 years of age not living in your home that we may contact HiddenName HiddenRelationship HiddenTelephone Part 4 – Background Check:Each family member who will be over 18 during the exchange year must sign the application & must individually complete a background check. Background check instructions will be emailed to you & also will be displayed on the thank you page when this form is submitted. HiddenPlease sign & date below:Today's Date* MM slash DD slash YYYY Family Member 1's signature*Family Member 2's signature (age 18+)Family Member 3's Signature (age 18+)Family Member 4's Signature (age 18+) Δ
