Student Name:

Student E-mail:

Date:

Sponsor Rotary Club:

Details of Hosting Club

Host Rotary Club:

Host Rotary Club District:  

Host Club Mentor’s Name:

Mentor’s Address:

Mentor’s Telephone Number:

Mentor’s E-mail:

Details of Present Host Family

Host Family Name:

Host Family Address:

Host Family Telephone Number:

Host Brothers & Sisters (Sex/Age) eg None, M/17, F/6, etc

Details of Next Host Family
Note: You must put something in these fields even if it’s “Don’t know”

Host Family Name:

Host Family Address:

Host Family Telephone Number:

Date of Anticipated Transfer:

Amount of Pocket Money received per month:

On Time? Yes No

Give a brief account of your contact with your Host Mentor since your arrival:

What contact has been made between Sponsor and Host Clubs (Emails, Letters, CDs, Bulletin exchanges, etc) since your arrival? What have you done to promote contact between Sponsor and Host Clubs?

What contact have you had with your Sponsor Club & Mentor (in WA) since your arrival?

What Rotary tours have been offered to you by the Host District? Give brief details of the Itinerary, duration and cost.

Which did you decide to take and why?

During the last month how has your relationship been with your: (give explanatory detail if appropriate)

Host Family

Host Club

Host Mentor

School

How have you gone about establishing your identity and acceptance at your school?

General (comments, requests, complaints, impressions - spill the beans!!!)

Activities Report
Note: You must put something in ALL fields of the Activity Report, even if it’s “Not applicable”.

Rotary Meetings attended

Public Speaking engagements and topics of talks

What is your total number of talks to date? 

Examples of the type of questions asked by the audience

Press, Radio & TV interviews

Contact with other Exchange Students

Give brief details of your social and sporting activities

What has been the highlight of the last month?

After completing ALL fields, click on the “Submit” Button to e-mail this report to your District 9450 Placement Officer. You will be transferred immediately to a confirmation webpage if you have successfully sent your report.