Eastern States Student Exchange

Please contact your local Rotary club BEFORE completing this application. Some clubs have additional application forms and/or rules. If you live in the Rotary ESSEX area and need help locating a club in your area, you may call our toll free number 1-888-ROTARY-X (1-888-768-2799). See the ESSEX Map for the areas of the USA, Canada and Bermuda that are part of ESSEX.

Short Term Application Download and associated forms

	Note: The link "Short Term Application" is a writable .pdf. This file can be downloaded to your desktop, completed, saved, and printed using the free version of Adobe Acrobat Reader. If you do not already have Adobe Acrobat, download it FREE here.

Instructions

Type in the requested information, including the name, address and phone number of your local Rotary Club chairman and your district chairman. E-mail addresses are greatly appreciated. ALL applications should be typed. It is easier to read and faxes
better. Scanning pictures onto the first and last pages works well.

The application does not print out well on some ink jet printers. We recommend that you fill out and print the application on a laser printer, if possible.

Print 5 copies. All copies must have original color photos and original signatures. All signatures must be in blue ink. Submit one ESSEX Short-Term Exchange Check List to your Rotary Club Youth Exchange Officer (YEO). The only part of this check list you need to complete is your last name and first name with a minimum of 3 country choices with #1 being your first choice of countries. The Rotary Club YEO and District Chair for Short-Term will complete the rest of the check list.

You have already completed your country choices on the check list, but it is very, very important that you communicate to your club chairman and/or your district chairman how flexible you are. For example, if you are willing to go to any Spanish–speaking
country, make sure your chairman advises us on your application checklist. If you will only go to your first choice or if there is somewhere you won’t go, let us know. Sometimes we are unable to get cooperation from the foreign contacts. When this happens having several options helps find you a suitable match.

Keep one copy of the application for your files. Mail or deliver your other 4 to the local Rotary club. The local Rotary club will interview you before referring your application to the district. If you are accepted for the program, the Rotary District Short-Term Chair
or Youth Exchange Chair will sign your application before it is sent onto ESSEX and a Rotary club in the host country.

To Apply for Medical Insurance

All students are required to carry the CISI-Bolduc medical insurance Policy Plan B with personal Liability Coverage. To download the application to complete and submit with your application package, please click on the "2011 CISI Insurance Application" link above, and then click on " Short Term Application Download and associated forms". A check payable to CISI-Bolduc must be sent along with the insurance application as part of the Application Package as follows:

For a 3-4 week each way exchange the 1 month policy B must be taken for the cost of $61.50

For a 6 week each way exchange the 3 month policy must be taken for the cost of $169.00

Associated Fees

The following checks must be submitted with your application:

• One payable to “ESSEX STEP” in the amount of $65.00, application fee
• One payable to CISI-Bolduc in the amount as indicated in the above Paragraph
• One payable to your Rotary district if there is a district fee.

Please check with your sponsoring District/Rotary Club for associated District fee.

Apply for Your Passport

Apply for your passport if you don’t already have one. Be sure to allow enough time for it to be processed.

Downloads for Youth Exchange Officers:

2012 ESSEX Short Term Exchange Handbook

2012 ESSEX Short Term Exchange Check List

2012 ESSEX STEP Application Procedure

2012 Instructions for a Club Short Term Exchange Chair

2012 Instructions for a District Short Term Chair