Acceptance Form

First Name *

Middle Name

Last (Family) Name *

Year Abroad

Birth Date *

// (mm/dd/yyyy)

Your age as of your departure date

Gender *

Your Mobile

Email

Address Type

Address 1 *

Address 2

City *

Country *

Post Code

Parents Names *

Parent #1 Email *

Parent #1 Mobile *

Sponsoring Rotary District *

Sponsoring Rotary Club Name

Shirt Size

Small
Medium
Large
Extra-Large
2X-L
3X-L

I am severely allergic to animals (this may make placement more difficult in Colorado)

I understand my DS-2019 and Guarantee Form will not be shared until my family and I have signed the required documents *

Yes
No

I understand I must show proof of CISI Bolduc (or similar/approved) Medical Insurance at my Visa Appointment covering the entire exchange year *

Yes
No

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