Rotary District 6250

District Governor

Kristin Duckart

Serving Western Wisconsin & Southeast Minnesota

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DISTRICT 6250 INBOUND YOUTH EXCHANGE STUDENTS

Student's Monthly Report Form

Date:
Student's Name:
Hosted by Rotary Club of:
Student Email:

Youth Exchange Officer's Name:
YEC Name:
YEO Email:
YEO Phone:

Current Host Family:

Street Address:

City:

Phone:

Host Email:

Host Mother's Name:

Host Father's Name:

Host Siblings (Names & Ages):

Next Host Family:
Anticipated Date of Move to Next Family:

Street Address:

City:

Activities since last report:

Tell us about your activities, such as public speaking engagements, social activities, places of interest you visted, contact with other exchange students and community projects and any newspaper, radio, or television interviews.

What subjects are being studied at school? (If no change, so indicate.)

How is your language proficiency progressing?

Rotary activities since last report

Number of Rotary club meetings attended

Have you attended any Rotary Youth Exchange meetings or conferences?

	Yes
	No

Describe:

Are you receiving your allowance regularly?

	Yes
	No

Amount:

Are you helping your Rotary club with a community service project?

	Yes
	No

Describe:

Has contact been made between your host Rotary club and sponsoring club?

	Yes
	No

Describe:

Are you corresponding regularly with:

Your family at home?

	Yes
	No

Describe:

Your sponsoring Rotary club?

	Yes
	No

Describe:

How is your relationship with:

Your host family

Your host Rotary club

Your school

Your fellow students

Your youth exchange officer

Have you met with your YEO this month?

	Yes
	No

Your youth exchange counselor

Have you met with your YEC this month?

	Yes
	No

Do you want the following section of this report to be kept confidential? Yes No

If you are having any difficulties or problems, please tell us about them. Don't hesitate to also tell us about the good times as well. Include any comments, suggestions, requests, complaints or impressions you may wish to share with us.

If you are reporting a problem, is it severe enough for us to intervene at this time? Yes No

Student Signature:

One copy of this form should be sent each month to the D-6250 Inbound Coordinator. If you have questions, contact Michelle Matthys at mmatthysrye@gmail.com