Family Application – Rocky Mountain Rotary Youth Exchange

Rotary Club*
Rotarian/Youth Exchange Officer full name*
YEO Email address*

A copy of this application will be emailed to this email.
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Country 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*
If 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*
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Street Address
City*
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 Phone
Business Phone
Cell Phone
Occupation
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 Phone
Business Phone
Cell Phone
Occupation
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 Phone
Business Phone
Cell Phone
Occupation
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Part 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.
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If no children in the home check this box
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Name 1
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DOB 1
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Relationship 1
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Education 1
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Hobbies 1
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Name 2
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DOB 2
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Relationship 2
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Education 2
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Hobbies 2
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Name 3
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DOB 3
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Relationship 3
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Education 3
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Hobbies 3
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Name 4
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DOB 4
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Relationship 4
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Education 4
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Hobbies 4
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Name 5
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DOB 5
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Relationship 5
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Education 5
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Hobbies 5
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Part 3 – Personal References:
At least three references must be contacted and one references contacted must be an immediate relative.
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Persons that are not relatives or former employers that we may contact.
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Name
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Occupation
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Telephone
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Name 2
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Occupation 2
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Telephone 2
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Name 3
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Occupation 3
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Telephone 3
Immediate Relative over 18 years of age not living in your home that we may contact
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Name
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Relationship
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Telephone
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.
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Please 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+)

Family Member over the age of 18 #2 (FM2)

Family Member over the age of 18 #3 (FM3)

Family Member over the age of 18 #4 (FM4)

Part 2 – Host Family Members under the age of 18:

Part 3 – Personal References:

Part 4 – Background Check:

Please sign & date below: