Witness (Sponsor Rotary club representative) Date (e.g., 01/Jan/2017) Home Phone E-mail Alternative Emergency Contact in home country Name Relationship Address — Street City State/Prov. Postal Code Country Home Phone Business Phone Mobile Phone E-mail (C) SENDING CLUB AND DISTRICT ENDORSEMENT The Rotary Club of Name of Club Club ID District # __________________ and 9910 District D9910 having interviewed the applicant and his/her parents/legal Club President Name Signature Email Address guardians and reviewed the student’s application, hereby endorse the student as qualified for Rotary Youth Date (e.g. 01/Jan/2017) Home Phone District Chair Name Exchange and recommend Peter Smith to host clubs the acceptance of this student. District agrees to provide adequate District Chair Signature Date (e.g. 01/Jan/2017) Home Phone orientation to the student 09 435 1391 and parents before the student’s departure District Chair Email Club Secretary/YEO Name Club Secretary/YEO Signature Pcs.rotary@gmail.com Date (e.g. 01/Jan/2017) Home Phone Club Secretary/YEO Email Applicant Name (D) HOST CLUB AND DISTRICT GUARANTEE (THIS WILL BE COMPLETED BY THE COUNTRY YOU ARE GOING TO) The Rotary Club of Name of Club Club ID District # __________________ will 9910 provide room and board in
Witness (Sponsor Rotary club representative) Date (e.g., 01/Jan/2017) Home Phone E-mail Alternative Emergency Contact in home country Name Relationship Address — Street City State/Prov. Postal Code Country Home Phone Business Phone Mobile Phone E-mail (C) SENDING CLUB AND DISTRICT ENDORSEMENT The Rotary Club of __________________ and District D9910 having interviewed the applicant and his/her parents/legal guardians and reviewed the student’s application, hereby endorse the student as qualified for Rotary Youth Exchange and recommend to host clubs the acceptance of this student. District agrees to provide adequate orientation to the student and parents before the student’s departure Name of Club Club ID District # 9910 Club President Name Signature Email Address Date (e.g. 01/Jan/2017) Home Phone District Chair Name Peter Smith District Chair Signature Date (e.g. 01/Jan/2017) Home Phone 09 435 1391 District Chair Email Club Secretary/YEO Name Club Secretary/YEO Signature Pcs.rotary@gmail.com Date (e.g. 01/Jan/2017) Home Phone Club Secretary/YEO Email Applicant Name (D) HOST CLUB AND DISTRICT GUARANTEE (THIS WILL BE COMPLETED BY THE COUNTRY YOU ARE GOING TO) The Rotary Club of __________________ will provide room and board in Name of Club Club ID District # 9910