Long Term Monthly Activity Report - DUE the 5th of EACH month

First Name

Last Name

Select Your Program *

Inbound (I am in USA)
Outbound (I am abroad)

Host Country *

Native Country *

Phone *

Host Parent Names *

Host Rotary Club *

Is your Counselor the same? *

Yes
No

Host School *

What Report is this?

Service Above Self Activities last month - Rotary or volunteer projects *

School and Social Activities last month *

Contact with Rotary *

Travel? Brags? Troubles? *

Teach Us - something you've learned, some phrases, unique customs... *

Please rate your host family *

Please rate your host club

Please rate your school performance *

How is your speaking and listening proficiency? *

How is your reading and writing progressing? *

How is your overall experience so far? *

How are your feeling? *

How often are you in touch with family and friends back home *

Rarely
Weekly
A couple times a month
A couple times a week
Everyday
Multiple times a day

How is your overall health? *

I need to talk to someone about an issue I need help with *

Yes - please contact me
No

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