Student Name:

Student E-mail:

Sponsor Rotary Club:

Sponsor Rotary Club District:

Host Rotary Club:

 District: 9450

Host Mentor’s Name:

Mentor’s Address:

Mentor’s Telephone Number:

Mentor’s Email:

Details of Present Host Family

Host Family Name:

Host Family Address:

Host Family Telephone Number:

Details of Next Host Family
Note: You must complete ALL fields even if you put “Don’t know”.

Host Family Name:

Host Family Address:

Host Family Telephone Number:

Date of Anticipated Transfer:

Name of School Currently Attending:

Give a brief account of your contact with your Mentor since your last report:

Have you experienced any problems, with Host Families, Host Club, Mentor or School since your last report? (You must put something in this field)

Comments, Suggestions, Requests, Complaints, etc
Include comments, requests, suggestions, complaints, impressions, and highlights etc.  Remember that comments on matters that you may regard as unimportant, could be of interest - ANYTHING different or unexpectedly similar to home. Suggestions to improve the Youth Exchange Program are especially welcomed and are important (You must put something in this field).

This report will be used to update this District's information on your current host family and address. Therefore, it cannot be stressed enough how important it is for this District to have your current address and telephone number.

After completing ALL fields, click on the “Submit” Button to e-mail this report to the Placement Officer. Note that you must enter information in ALL fields for the Report to be submitted successfully. You will be transferred immediately to a confirmation webpage if you have successfully sent your report.