ROTARY HOLIDAY EXCHANGE PROGRAM

DISTRICT 1620 BELGIUM

Youth Officer : Paul DEMOULIN
Rue Profondrieux 29
B-7190 Ecaussinnes
Tel +32 67 44 27 69
Email :pauldany_demoulin_rotary_yeo@hotmail.com

Concerns : a 10-Day Roundtrip in Belgium. January 2011

Dear Rotarian,

R.I. District 1620 invites 20 young people from the EEMA Region to a roundtrip in Belgium
in July 2011 . Theme : « BELGIUM , COUNTRY OF CONTRASTS »

Participants : Girls and boys aged 18 -22,sponsored by a Rotary Club.

All the participants are expected to be fully acquainted with the rules of the
Youth Exchange Program and to be ambassadors of their countries.

Duration : From 1st July to 10th July 2011.

Arrival - Departure : Brussels Airport or Brussels South Airport or Brussels South

railwaystation.

Program : Visits to important Belgian cities and regions.

A detailed program will be sent to participants in June

Accommodation : Participants will be accommodated by Belgian families.

Costs : Participants will pay for their travel costs to Belgium and back.

Insurance : Each participant must be fully insured against accidents, sickness and third party
liability according to the existence of an agreement or not between his/her home
country and Belgium.

Language : Participants are expected to have a working knowledge of English.

Application : Printed application forms,in triplicate, with passport photos must be sent before
May 15th to : RTN Virginie VANDENABEELE
Rue du Seigneur 32 Bte 19
B-7110 La HESTRE.
Tél: 32 499 96 79 88
E-mail : virginie.vandenabeele@ucb.com

We have the pleasure to invite 1 girl OR 1 boy from your country. In the meantime, we
remain
Yours in Rotary,

Paul DEMOULIN
Virginie VANDENABEELE
 ROTARY INTERNATIONAL
SUMMER CAMPS
Districts 1620-1630-2170
Jean Claude WARNANT
La Tassenière 13 , B-5500 DINANT BELGIUM
Tf++32(0)82-224343 Fax :++32(0)82-224343
e-mail: warnant.jc@gmail.com

DISTRICT 2170
BELGIUM
Dear friend,

District 2170 Belgium invites you, if you are certified, to send one boy and one girl from your
country or district to his annual holiday tour.

DISCOVER BELGIUM 2011-CROISIERE GEORGES HERZET

DATE : From Sunday 3 July 2011 to Saturday 16 July 2011.

ARRIVAL – DEPARTURE : BRUSSELS AIRPORT or BRUSSELS SOUTH STATION

PROGRAM : Visit Brussels area, Antwerp, Bruges, The Flanders, The Ardennes,
Waterloo….

The first four nights in Youth Hostel, the remaining with Rotarian families.
LANGUAGE : Participants are expected to have a working knowledge in English.
AGE : 16 (not younger that 16 in July 2010) – 18 ( not older that 18 in July 2010)

INSURANCE : All participants must be insured against illness, accident and third party
damages according to Rotary International recommendations.
If there is no insurance the participant will pay 50€ for this insurance when arriving in
Belgium.
Full accommodation will be provides by the district 2170 Belgium.

CLOSING DATE : A lot of invitation is being sent out. The number of participants is
however limited to the first 24 registered.
Acceptance will be made in order of entry of the completed application form.
No application will be accepted after 15th May 2011.

APPLICATION FORMS : Pages 3 – 7 + B:

TO BE SENT IN DUPLICATE to :

RTN Christian COGNEAU

Avenue Franklin Roosevelt 182
1050 BRUXELLES BELGIUM
Phone : +32 2 7708847 Mobile : +32 475 709093 E-mail : Christian.cogneau@numericable.be

Important note :
Please let me know immediately if your candidate fails to come in order to give another
candidate the possibility to participate.
Sincerely yours in Rotary,

Jean Claude WARNANT,

1
 ROTARY INTERNATIONAL
SHORT TERM PROGRAMME –SUMMER CAMPS
Districts 1620-1630-2170 CHAIRMAN
Jean Claude WARNANT
La Tassenière 13 , B-5500 DINANT BELGIUM
Tf++32(0)82-224343 Fax :++32(0)82-224343
E-mail: warnant.jc@gmail.com

DISTRICT 2170
BELGIUM

Dear Friend,

District 2170 Belgium invite you, if you are certified, to send one boy OR one girl from your
country or district to their annual holiday tour.

CROISIERE JEAN van EECKHOUT 2011

DATE : From 15 August to 26 August 2011

ARRIVAL : BRUSSELS Airport
DEPARTURE : BRUSSELS Airport

PROGRAM : A detailed program will be sent to the participants

LANGUAGE : Participants are expected to have a working knowledge in English.
AGE : 18 – 24 years old
INSURANCE : All participants must be insured against illness, accident and third party
damages according to Rotary International recommendations.
If there is no insurance the participant will pay 50 € for this insurance when arriving in
Belgium.
Full accommodation will be provided by the district 2170 Belgium and several Rotary Clubs,
Antwerpen-Zuid, Antwerpen Amerloo, Boom Rupel, Antwerpen-Oost, Antwerpen-Park,
Antwerpen-West, Mechelen Opsinjoor and Rotaract Club Antwerpen Centre.

CLOSING DATE : A lot of invitations are being sent out. The number of participants is
however limited to the first 20 registered.
Acceptance will be made in order of entry of the completed application form.
No application will be accepted after 31 May 2011.

COORDINATOR : Baudouin THYS RC Antwerpen Park : Baudouin.thys@pandora.be

APPLICATION FORMS : TO BE SENT IN DUPLICATE to :

RTN Jean-Louis LAENENS

Hazeschransstraat , 3
2650 EDEGEM
Phone : 03/4407187
GSM : +32 472 47 96 49
Email : jean.louis.laenens@telenet.be
Important Note :
Please let me know immediately if your candidate fails to come in order to give another
candidate the possibility to participate.
Sincerely yours in Rotary, Jean Louis LAENENS
1
 ROTARY INTERNATIONAL
SHORT TERM PROGRAMME –SUMMER CAMPS
Districts 1620-1630-2170 CHAIRMAN
Jean Claude WARNANT
La Tassenière 13 , B-5500 DINANT BELGIUM
Tf++32(0)82-224343 Fax :++32(0)82-224343
e-mail: warnant.jc@gmail.com

DISTRICT 1630
BELGIUM

Dear Friends in Rotary,

District 1630 Belgium invite you, if you are certified, to send one boy or one girl from your
country or district to his annual holiday tour.

“BELGIUM ’@’ THE BORDERS”

DATE : 24 July 2011 to 7 August 2011

ARRIVAL/DEPARTURE : BRUSSELS Airport followed by train to TURNHOUT
LOCATION : Hoogstraten/Turnhout-Houthalen/Zonhoven and surrounding cities.
PARTICIPANTS : 20 participants from the EEMA Zone ( boys and girls)
PROGRAM : 4 Rotary clubs have the pleasure to host the programme.
( Hoogstraten/Turnhout and Houthalen Midden Limburg/Zonhoven)
This programme will include cultural visits, sports, and tourism activities.
Family stays will be the basement of it.
A detailed program will be sent to the participants
AGE : 17 – 19 years old
LANGUAGE : English (area usual language is Flemisch)
ACCOMODATION : The participants will be hosted by Rotarian families.
COSTS : Travel to and from Belgium – Pocket money to cover personal and private expenses
during the stay. All accommodation including food are covered by the organization.
WEATHER CONDITION : July/August should be a sunny and warm (+/- 24°C) season.
Nevertheless Belgium has the poor habit to have some rains even in summer and it can be
cold.
DRESSING : Easy and cool dressing should be the rules. Water sport, bike and walking
activities will be in the programme.
INSURANCE : All participants must be insured against illness, accident and third party
damages according to Rotary International recommendations.
CLOSING DATE : A lot of invitation is being sent out. The number of participants is
however limited to the first 20 registered.
Acceptance will be made in order of entry of the completed application form.
No application will be accepted after 15 May 2011.

APPLICATIONS FORMS : TO BE SENT IN DUPLICATE to :

RTN Heidi VAN DER AUWERA

Kasteellaan , 6
3450 GEETBETS
Phone:+32 11 58 98 18 Mobile : +32 472 90 30 53
Email : tandarts.heidi@belgacom.net

1
 ROTARY ITERATIOAL
YOUTH EXCHANGE PROGRAM DISTRICT 2482 BULGARIA

Invitation to the
ROTARY “Meet Bulgaria Unique harmony of ature” SUMMER CAMP
2 July to 11 July 2011

WELCOME TO THE BLACK SEA PEARL

Host Country: Bulgaria

Host Club: Rotary Club of Nessebar (District 2482)
Aim of Camp: Sun bathing, sailing, exploring mountains and visits of ancient Bulgarian towns
Program: A detailed program will be sent to the participants before their arrival
Participants: 8 girls and boys, one participant per Rotary District
Age: 18 - 21
Language: English
Accommodation: Mariner Hotel, Sunny Beach
Insurance: All participants must be insured against illness, accident and third party damages according
to RI recommendations, as well as insuring their personal effects.
Participation Fee: 200 EUR, paid after arrival.
Arrival: 2nd July 2011, Bourgas Airport (BOJ) Bulgaria. A Rotarian or a tour guide will pick the
participant up
Departure: 11th July, Bourgas Airport (BOJ) Bulgaria. A Rotarian or a tour guide will take the
participant to the airport
Application Forms: A scanned PDF AF (STEP) must be sent to:
Nikolay Nikolov
Chairman RYEP D2482, Bulgaria
ryep@rotarydistrict2482.org
Deadline: 30th April 2011.
Things to bring: 2 pennons from the sponsor Rotary Club, casual wear, trainers and swimsuit
 ROTARY INTERNATIONAL
ROTARY YOUTH EXCHANGE
bbbbb
SUMMER CAMPS

DISTRICT 2240 – CZECH REPUBLIC

Dear friends,

District 2240 - Czech Republic invites you, if you are certified, to send one boy or one
girl from your country or district to the Czech Summer Camp

Biking, Hiking and Sightseeing in

Bohemian-Moravian Highland

SPONSOR DISTRICT AND CLUBS:

D – 2240, RC Jihlava, RC Třebíč, RC Telč

WHERE: Czech Republic, Bohemian-Moravian Highland, Prague

WHEN: Saturday, August 6, 2011 - Saturday, August 20, 2011

ARRIVAL: Prague Airport (Praha – Ruzyně) August 6, 2011

DEPARTURE: Prague Airport (Praha – Ruzyně) August 20, 2011

PARTICIPANTS: 16 – 18 years old, one boy or one girl from each country,
16 participants altogether.
The first 16 will be accepted.

LANGUAGE: English

PROGRAMME: Biking through forest pathways and country roads, hiking,

free nature sports activities, tennis, mini-golf, volleyball,
sightseeing, visits of historic monuments of the region,
visit of Prague.
Detailed program will be sent to each participant.

NECESSARY ABILITIES OF EVERY PARTICIPANT:

Ability to bike 40 km on mountain bike daily in hilly terrain.

EQUIPMENT: Bike helmet, sportswear, hiking shoes, raincoat.

ACCOMODAT.: Hotel – Pension Dobra Voda first week, bungalows Sportland
in Litohor close Trebic second week. Student hostel in Prague.
Full pension will be provided.

COSTS: Travel expenses to and from the camp, pocket money,

Mountain bikes rent – 80 EUR per person.

INSURANCE: Health insurance, third party liability risk insurance.

APPLICATIONS: Applications forms, pages 3 – 7 + B, to be send in duplicate before

April 30, 2011 to

Rtn. Jan Bílek

Chelčického 948/34,
CZ-290 01 Poděbrady
CZECH REPUBLIC

Phone : +420 325 625 824,

Cell. : +420 602 204 446
Email : jan.bilek@rotary2240.org

CONTACT: Rtn. Pavel Toman

Stabařů 26
586 01 Jihlava
CZECH REPUBLIC

Phone and fax: +420-567 310 100

Cell.: +420-603 871 389
E-mail: ptoman@ssstavji.cz
 ROTARY INTERNATIONAL
ROTARY YOUTH EXCHANGE
bbbbb
SUMMER CAMPS

DISTRICT 2240 – CZECH REPUBLIC

Dear friends,

District 2240 - Czech Republic invites you, if you are certified, to send
one boy or one girl from your country or district to

INTERNATIONAL FILM SUMMER CAMP

Organized by School club at High school Jiřího Wolkera in Prostějov

in cooperation with Students’ Theatre POINT, Municipal Library in
Prostějov
and
Rotary club Prostějov, District 2240
.
Dates: Tuesday 26th JULY to Thursday 4th AUGUST 2011
(Participants can arrive on 25th July)

Arrival: Monday 25th JULY, from 12.00 am to 19.00 pm,

Czech Republic, the city of Prostejov, hotel reception AVION
www.avion.prostejov.cz
http://maps.google.cz/maps?hl=cs&tab=wl
GPS 49.472311, 17.11538

Departure: Thursday 4th or Friday 5th AUGUST from Prostějov

Host Club: RC Prostějov / District 2240

Participants: 12 (1 BOY or 1 GIRL from your country) 18 - 24 years

old at the beginning of the camp

Aim of the camp: To make a film. Participants can train creative skills in artistic
workshops: Filming/Editing film, Acting, Dancing,
Musical/Singing, Stage and Costume designing.
Meeting Czech literature – Inspirited writing.

Program: A detailed program will be sent later by the Organizer

Technical equipment:
Main camera Canon XL2, Pinnacle Studio 14, Adobe After
Effects, PCs with PS 14 for each group, professional camera
crane, lights and other equipment.
Your own camcorder or camera recommended but not
demanded.

Description of the camp / accommodation:

In the village called Sobotín
http://maps.google.cz/maps?hl=cs&tab=wl
GPS 50.022961, 17.077121
(near by the Moravian town Šumperk).

The camping ground is situated in the woods by the stream near

the village of Sobotín, accommodation in cabins (four-beds), 2
solid sport courts, 2 common rooms, 1 roofed stage, separated
male and female toilets, shared lavatory and showers,
swimming-pool nearby.
Sleeping bag needed.

Languages: English,

Registration Fee: Payment of 50 € must be sent to the club for confirmation. Upon
arrival, each participant will be paid back the full amount in cash
in CZK or EUR.

Insurance: The participants must be insured against illness, accident and

third party damages according to Rotary International
recommendations.

Application: Applications forms. Pages 3 – 7 + B, to be send in duplicate

before April 30, 2011 to

Rtn. Jan Bílek

Chelčického 948/34,
CZ-29001 Poděbrady
CZECH REPUBLIC

Tel. : +420 325 625 824,

Cell. : +420 602 204 446
Email : jan.bilek@rotary2240.org

Contact RC Prostějov: Ladislav Burgr,

Určická 31,
CZ-79601 Prostějov
CZECH REPUBLIC

Tel: +420 602 203 427

Email: ladislav.burgr@seznam.cz
For more information you can visit the following websites:

website to theatre POINT www.divadlopoint.cz

film camp Sobotín 2010 www.divadlopoint.cz/filmovy-tabor-sobotin
or Facebook http://www.facebook.com/FilmovyTabor

Camp Sobotín:

around camp:
 Rotary Youth Exchange
Short-Term Summer Tour(STEP) Application

Submit completed application in triplicate to: Kertész Béla

4024 DEBRECEN, Klaipeda u. 4.
Tel/Fax: 52-411-504
Mob: 30-2996174
Or in scanned form to
kertesz.bela@rotary.hu

General Information and Instructions

Types of Short Term Summer Tours

Youth Camps and Tours

(Ages 15-24 as determined by the organisers of the individual camp or tour)

General Application Pages 3-7 and Supplementary Page B for Summer

Tour/Camp

These camps bring together participants from several countries and take place usually in summer. Camps may have
themes such as sports, culture, nature, language, computer or participation in a community service project. Some camps
provide leadership training and address international concerns. By bringing together international participants, camps
promote cultural tolerance and international understanding through friendship.
Where possible young people with disabilities will be included in the camp or tour programs, however for the more
severely disabled special camps known as 'Handicamps' are organised where participants can be assisted by a carer.
In addition to this Application Form further information from participants will be required by the organisers.

Page 1

Read all directions on each page carefully before completing the application. Use the checklist on the last page to ensure
that you have completed all sections and obtained all necessary signatures.
If you are accepted into the short term program this application will be sent to the hosting country and will serve
as your introduction to the people who will organize your stay or host you.
Components of Your Application
• General Information: Pages 3 - 7 containing your Personal Information, Acceptance of the Rules and Conditions
and the Guarantee Form;
• Supplementary Information: Pages A, B or C dependent upon the program in which you wish to participate;
• Copy of your passport or birth certificate.

Completing your Application

Your application must be legible. Typed or computer-generated applications are strongly encouraged.
Answer all questions completely and as asked (do not write “same,” “see above,” or “see page __”). Enter the information
into the space provided unless directed otherwise. To avoid any chance of misinterpretation take care with your grammar
and spelling.
Wherever the application asks for your full legal name, enter your name exactly as it appears on your passport or birth
certificate. On pages that have a box in the upper right-hand corner marked “Applicant Name”, enter the preferred form of
your name. For example, an applicant whose full legal name is Joseph David Smith might enter Joseph Smith or Joe Smith.
Printing Your Application and Signing the Forms
Submit four complete sets of this application. (You may also wish to make an additional set for your own records.) Sets 2-4
can be good quality photocopies, or if you can scan the original application form just fill the original application and scan with
all signatures. On all copies the signatures must be ORIGINAL and in BLUE. To achieve this:
1. Complete the application form but do not sign it.
2. Print four sets of the completed application (or if using a typewriter or completing by hand, make three good-quality
photocopies of the original, also possible is to complete one and scan and mail the application form.)
3. Add your signature and those of your parents/legal guardians to all copies, or to one if you scan and mail the
application form.
The photo of yourself on Page 3 may be digitally inserted or attached. If attached it must be an original photograph on all
sets, not a color photocopy, The other three sets may be good-quality color photocopies. You may scan it in PDF and mail
the application!!
Questions?
If you have any questions about completing this application, check with your local Rotary Club’s Youth Exchange officer.
Once you’ve completed your application, return it to your local Rotary Club/District as instructed.

Data Protection
Your information will be shared with Rotary International, the Sending and Hosting Rotary Districts Youth Exchange Organizations’ and Clubs, your
appointed counselor and host families. It will only be used for official RI business and not sold to or shared with other third parties, unless required by
law to be released.

Statement of Conduct for Working with Youth

Rotary International strives to create and maintain a safe environment for all youth who participate in Rotary activities. Rotarians, Rotarians’
spouses, partners, and other volunteers must safeguard the children and young people they come in contact with and protect them from physical,
sexual and emotional abuse.
Adopted by the Rotary International Board of Directors, November 2006

Page 2
 Short-Term Summer Tour/Camp Smile!
Attach or insert a recent, good-quality
Program color photo of yourself (head and
shoulders).
Personal Information Original photos must accompany all
four sets of the application.
Before you begin your application, please Attach photo with glue or
read all instructions on the prior pages. double-sided tape; do not staple.
Passport Size

1. Program Information
This application refers to the following Short Term Exchange Program (please tick the appropriate box):
Family to Family Individual Exchange New Generations Individual Exchange
Group Exchange / Tours New Generations Group Exchange
Youth Camps Other

2. Applicant Information
Full Legal Name as on passport or birth certificate (use capital letters for your FAMILY name; e.g., SMITH John Name You Wish to be Called Male
David)
Female

Date of Birth (e.g., 23/April/2008) Citizen of (Country) Place of Birth (City, State/Province, Country)

Home Address – Street Town/City State/Province Postal Code Country

Postal Address (if different) - Street Town/City State/Province Postal Code Country

E-mail Address Home Phone Number Mobile Phone Number

3. Parent/Legal Guardian Information (Preferred but not essential if applicant is over 18 years of age)
Full Name of Father/Legal Guardian Rotarian? If yes, name of Rotary Club

Yes No

Address – Street Town/City State/Province Postal Code Country

E-mail Address Home Phone Number Mobile Phone Number

Occupation Business Phone Number Fax Phone Number

Full Name of Mother/Legal Guardian Rotarian? If yes, name of Rotary Club

Yes No

Address – Street Town/City State/Province Postal Code Country

E-mail Address Home Phone Number Mobile Phone Number

Occupation Business Phone Number Fax Phone Number

Parent/legal guardian to contact first in the event of an emergency (specify “Father”, “Mother”, etc.):

Check here if your parents are divorced or separated. If applicant is under 18 authorizations must be obtained from all parents/legal guardians and
others who have legal rights to decisions affecting the student’s participation. Explanation is required if signatures of two parents or legal guardians
are not provided.

Page 3
 Applicant’s Name

4. Personal Background
Religion Do you have any special requirements regarding religious observance? Please detail:-

Dietary Restrictions (Enter “None”, or explain with details – e.g., vegetarian, vegan, allergic to…)

Do you smoke or use tobacco products? If yes, please explain.

Yes No

Do you drink alcohol? If yes, please explain.

Yes No

Have you ever used illegal drugs? If yes, please explain.

Yes No

Answering yes to these questions will not automatically eliminate you as a candidate; however, it may require special consideration of host family or host
country.

5. Languages
Your Native Language
Proficiency in Non-Native Language(s)
(indicate Poor, Fair, Good, or Fluent)
Non-Native Language(s) Years Studied Speaking Reading Writing

6. Health Declaration
Do you have any mental health/medical/dental conditions? Yes No
Have you been treated for mental health/medical conditions in the past two years? Yes No
Have you taken any prescribed medications in the past six months? Yes No
Do you have any special health requirements (disabilities, allergies etc.)? Yes No
If you have answered ‘YES’ to any of the above please explain fully in the space below providing as much information as possible, including the name of
any medication and the reason prescribed and include a copy of the doctor’s prescription. Use additional sheets of paper if necessary.

For more personal and background information please use the appropriate Supplementary Page.

7. Sending District and Club Contacts (to be completed by Sending Rotary Club and District representatives)
Sending District Number Name of Sending District Youth Exchange Chair E-mail Address

Address – Street Town/City State/Province Postal Code Country

Home Phone Number Business Phone Number Mobile Phone Number Fax Number

Sending Rotary Club Name of Sending Club Youth Exchange Officer E-mail Address

Address – Street Town/City State/Province Postal Code Country

Home Phone Number Business Phone Number Mobile Phone Number Fax Number

Page 4
 Applicant’s Name

Short-Term Summer Tour Program

Rules and Conditions of Exchange,
Permissions and Declarations
As a Youth Exchange Program participant supported by a Rotary club or district, you must agree to the following rules and conditions of
exchange. Violation of any of these rules may result in dismissal from the program and immediate return home, at your expense. Please
note that districts may edit this document or insert additional rules if needed to account for local conditions.

Rules and Conditions of Exchange

1) You must obey the laws of the host country. If found 7) You must purchase return travel ticket before departure
guilty of violating any law, you can expect no assistance from the home country.
from your sponsors or native country. You must return 8) You must attend all orientations and trainings offered by
home at your own expense as soon as released by the sending and host districts and clubs.
authorities.
9) You must have sufficient financial support to assure your
2) You will be under the host district’s authority while you well-being during your exchange. Your host district may
are an exchange program participant and must abide by require a contingency fund for emergency situations.
the rules and conditions of exchange provided by the Unused funds will be returned to you or to your parents
host district. Parents or legal guardians must not or legal guardians at the end of your exchange.
authorize any extra activities directly to you. Any
relatives you may have in the host country will have no 10) You must follow the travel rules of your host district.
authority over you while you are in the program. Travel is permitted with host parents or for Rotary club or
district functions authorized by the host Rotary club or
3) You are not allowed to possess or use illegal drugs. district with proper adult chaperones. The host district
Medicine prescribed to you by a physician is allowed. and club, host family and if you are under 18, your
4) The illegal drinking of alcoholic beverages is expressly parents or legal guardians must approve any other travel
forbidden. Students who are of legal age should refrain. in writing, thus exempting Rotary of responsibility and
If your host family offers you an alcoholic drink, it is liability.
permissible to accept it under their supervision in the 11) You must return home directly by a route mutually
home. agreeable to your host district and, if under 18, your
5) You may not operate a motorized vehicle, including but parents or legal guardians.
not limited to cars, trucks, motorcycles, aircraft, all- 12) Any costs related to an early return home or any other
terrain vehicles, snowmobiles, boats, and other unusual costs (language tutoring, tours, etc.) are the
watercraft, or participate in driver education programs. responsibility of you and your parents or legal guardians.
6) You must have travel insurance that provides coverage 13) You should communicate with your host family, if
for accidental injury and illness, third party liability, death applicable, prior to leaving your home country. The
benefits (including repatriation of remains), disability/ family’s information must be provided to you by your host
dismemberment benefits, emergency medical club or district prior to your departure.
evacuation, emergency visitation expenses, 24-hour
emergency assistance services, and legal services, in 14) Visits by your parents or legal guardians, siblings, or
amounts satisfactory to the host Rotary club or district, friends while you are on exchange are strongly
with coverage from the time of your departure from your discouraged. Such visits may only take place with the
home country until your return. consent of the host club and district and within their
guidelines.
15) Talk with your host counselor or other trusted adult if you
encounter any form of abuse or harassment.

Recommendations for a Successful Exchange

1) Smoking is discouraged. If you state in your application 5) Avoid serious romantic activity. Abstain from sexual
that you do not smoke, you will be held to that position activity.
throughout your exchange. 6) Do not borrow money. Pay any bills promptly. Ask
2) If placed in a host family, respect your host’s wishes. permission to use the phone or computer, keep track of
Become an integral part of the family, assuming duties all calls and time on the Internet, and reimburse the costs
and responsibilities normal for a person of your age or you incur.
for children in the family. 7) Limit your use of the Internet and mobile phones.
3) Make an effort to learn the basics of the language of the Excessive or inappropriate use is not acceptable.
host country. 8) If you are offered an opportunity to go on a trip or attend
4) Attend Rotary-sponsored events and, if living with a an event, make sure you understand any costs you must
family, host family events, and show an interest in these pay and your responsibilities before you go.
activities. Volunteer to be involved - do not wait to be
asked.
Page 5
 Applicant’s Name

PERMISSION FOR MEDICAL CARE AND RELEASE FROM LIABILITY

I, the applicant, do release from liability and grant permission as noted of the following while I am participating as a Rotary Youth Exchange
program participant:
• In the event of accident or sickness, I authorize any Rotarian, authorized chaperones of Rotary activities, and/or host parent(s) of
the student to select the appropriate medical facility and physician(s)/dentist(s) to provide treatment.
• I give permission for any operation, administration of anesthetic, or blood transfusion that a medical practitioner may deem
necessary or advisable.
• I further consent to any medical or surgical treatment by a licensed physician, surgeon, or dentist that might be required for any
emergency situation.
I agree to hold harmless Rotary International, any Rotary District or Club, Rotarian, Rotary chaperone, or host family for any intervention in an
emergency situation regardless of final outcome. I agree to assume all financial obligations beyond those covered by insurance for any
medical treatment rendered.
PARENTAL PERMISSION FOR MEDICAL CARE AND RELEASE FROM LIABILITY (delete if Applicant is over 18)
We, the parents/legal guardians of the applicant who have the sole and legal right to make the decisions on the health and care of the
applicant, do release from liability and grant permission as noted of the following while our son/daughter/ward is participating as a Rotary
Youth Exchange student:
• In the event of accident or sickness, we authorize any Rotarian, authorized chaperones of Rotary activities, and/or host parent(s) of
the student to select the appropriate medical facility and physician(s)/dentist(s) to provide treatment.
• We give permission for any operation, administration of anesthetic, or blood transfusion that a medical practitioner may deem
necessary or advisable for the treatment of our son/daughter/ward.
• We further consent to any medical or surgical treatment by a licensed physician, surgeon, or dentist that might be required by our
son/daughter/ward for any emergency situation. We do request that we be notified as soon as possible, but emergency treatment
need not be delayed to provide such notice.
• In the case of elective surgery, we request that we be notified and our permission obtained before such arrangements are made.
We agree to hold harmless Rotary International, any Rotary District or Club, Rotarian, Rotary chaperone, or host family for any intervention in
an emergency situation regardless of final outcome.
We agree to assume all financial obligations beyond those covered by insurance for any medical treatment rendered.
APPLICANT’S DECLARATION
IN CONSIDERATION of the acceptance and participation of the applicant in this program, the undersigned APPLICANT to the full extent
permitted by law, hereby releases and agrees to defend, hold harmless, and indemnify all host parents and members of their families, and all
members, officers, directors, committee members, and employees of the host and sponsor Rotary clubs and districts, and of Rotary
International, from any or all liability for any loss, property damage, personal injury, or death, including any such liability that may arise out of
any negligent act or omission, excepting gross negligence or intentional conduct, of any such persons or entities, which may be suffered or
claimed by such applicant, parent, or guardian during, or as a result of, the participation by the applicant in such Youth Exchange program,
including travel to and from the host country.
As the undersigned applicant I declare that:-,
• I have read and understood the Program Rules and Conditions of Exchange and agree to abide by these rules and others imposed
on me with due notice during my time as an exchange student in the host country.
• I have read and understand the Statement of Conduct for Working with Youth. I understand that all Rotarians and host families are
expected to have read and understood this statement. I understand that I will be provided with training and written material on whom
to contact and procedures I must follow should I encounter any form of abuse or harassment.
• I am in good health and as a Rotary Youth Exchange participant understand the importance of the role of a youth ambassador and,
should I be chosen to represent my sending Rotary club and district, school, community, state/province, and country will, to the best
of my ability, maintain the high standards required. I further state that all the detail entered by me in this application and the
attached documents are true and accurate to the best of my knowledge.
DECLARATION BY PARENTS/LEGAL GUARDIANS (delete if Applicant is over 18)
IN CONSIDERATION of the acceptance and participation of the applicant in this program, WE, his/her PARENTS or LEGAL GUARDIANS, to
the full extent permitted by law, hereby release and agree to defend, hold harmless, and indemnify all host parents and members of their
families, and all members, officers, directors, committee members, and employees of the host and sending Rotary clubs and districts, and of
Rotary International, from any or all liability for any loss, property damage, personal injury, or death, including any such liability that may arise
out of any negligent act or omission, excepting gross negligence or intentional conduct, of any such persons or entities, which may be suffered
or claimed by such applicant, parent, or guardian during, or as a result of, the participation by the applicant in such Youth Exchange program,
including travel to and from the host country.
As the undersigned parents or legal guardians of the applicant:
• We have read and understood the Program Rules and Conditions of Exchange and agree to abide by them.
• We have read and understood the Statement of Conduct for Working with Youth and we understand that all Rotarians and host
families are expected to have read and understood this statement.
• We agree that the Applicant may travel to the Host District
Signed (Applicant) Signed (Father/Guardian) Signed (Mother/Guardian)

Witness (Sending Rotary club representative) Date (e.g., 01/Jan/2006)

Alternative Emergency Contact in home country, OTHER THAN A PARENT/GUARDIAN

Name Relationship

Home Address – Street Town/City State/Province Postal Code Country

E-mail Address Home Phone Number Business Phone Number Mobile Phone Number

Page 6
 Applicant’s Name

Short-Term Summer Tour/Camp

Guarantee Form
Full Legal Name as on passport or birth certificate (use capital letters for your FAMILY name; e.g., SMITH Name You Wish to be Called
John David) Male
Female
Place of Birth (City, State/Province, Country) Citizen of (Country) Date of Birth (e.g., 01/Jan/1999)

SENDING CLUB and DISTRICT ENDORSEMENT

The Rotary Club and Rotary District specified within this section, having interviewed the applicant and his/her parents/legal guardians* and
having reviewed the application, hereby endorse the student as qualified for Rotary Youth Exchange and recommend to hosting clubs and
districts the acceptance of this student. The District agrees to provide adequate orientation to the student and parents* before the student’s
departure. *delete if applicant over 18)
Sending District No. Sending Club Name Sending Club ID No.

Name of District Youth Exchange Chair Name of Club President Name of Club Secretary / YEO

Signature of District Youth Exchange Chair Signature of Club President Signature of Club Secretary/YEO

Date (e.g., 23/April/2008) Date (e.g., 23/April/2008) Date (e.g., 23/April/2008)

HOST DISTRICT and CLUB GUARANTEE

The Rotary District, and Rotary Club where specified within this section, will provide room and board in approved homes, invite the applicant
to participate in Rotary club and district events and activities typical of our country, and provide guidance and supervision to assure the
applicant’s welfare. The host Rotary District agrees to provide adequate training for host parents and Youth Exchange volunteers and
orientation for the student upon his/her arrival.
Host Country Host District No. Host Club Name Host Club ID No.

Name of District Youth Exchange Chair Name of Host Club President Name of Host Club Secretary /YEO

E-mail Address of District Youth Exchange Chair E-mail Address of Host Club President E-mail Address of Host Club Secretary/YEO

Signature of District Youth Exchange Chair Signature of Host Club President Signature of Host Club Secretary/YEO

Date Home Phone Number Date Home Phone Number Date Home Phone Number

HOST DISTRICT or CLUB COUNSELOR (Individual Exchanges only)

Name E-mail Address

Address – Street Town/City State/Province Postal Code Country

Home Phone Number Business Phone Number Mobile Phone Number Fax Number

Page 7
 Applicant’s Name

Short-Term Summer Tour supplementary B

Supplemental information about applicants for

Youth Camps and Tours

Applicant’s Personal Background

Please answer the following questions:-

What are your free time activities?

What are your school, college or university education attainments and vocation?

What are your special interests and accomplishments?

Do you have special skills?

Could you contribute to entertainment (e.g. play musical instrument etc.)?

What is the reason for your programme participation (e.g. choice of specific youth camp)?

Other personal remarks.

 ROTARY INTERNATIONAL
District 1911 Hungary - Youth Exchange Program
Béla Kertész YEP Chairman. H-4024 DEBRECEN, Klaipeda str 4.
Tel/Fax: +36-52-411-504, Mob: +36-30-299-6174
E-mails: kertesz.bela@rotary.hu and kebehu@yahoo.com

Dear Fellow Youth Exchange Officers,

The Hungarian YEO hereby invites young people from your District to join
the Summer camp in Hungary: HUNGARIAN BRIDGE 2011

Please use the application forms for EEMA-camps and advise the applicant to fill in the application
forms by typing or by using block letters. Would you please send the forms as soon as possible,
but before 30th of April at the latest to my e-mail or to post-address.

Please confirm receipt of this invitation. Thank you very much for your co-operation.

Debrecen, 2011. January 24.

Béla Kertész
chairman
 ROTARY INTERNATIONAL
District 1911 Hungary - Youth Exchange Program
Béla Kertész YEP Chairman. H-4024 DEBRECEN, Klaipeda str 4.
Tel/Fax: +36-52-411-504, Mob: +36-30-299-6174
E-mails: kertesz.bela@rotary.hu and kebehu@yahoo.com

SUMMER CAMP IN HUNGARY

NAME: HUNGARIAN BRIDGE 2011

WHERE: Budapest - Szentendre

WHEN: 10. July – 23. July

Family Period: 10.July – 16 July
Camp Period: 16. July – 23. July

ARRIVAL: Budapest – Ferihegy, 10. July

DEPARTURE: Budapest – Ferihegy, 23. July

PARTICIPANTS: 9 boys and 9 girls, together 18 participants from EEMA countries.

AGE: 15-17 years (during the camp period

PROGRAMME: The camp consist of two parts. The first part is to spend one week not in the
capital with Hungarian families to get an idea of the Hungarian country lifestyle.
After this family week the participants will meet in Budapest stay in a youth sports
hostel. The camp programme (up to the weather) contains:
Day A: Budapest 1. (sightseeing, Parliament, chair-lift, fun-fair, Zoo)
Day B: Budapest 2. (museum, Citadella, the Royal Palace of
Buda, Evening walk, 3D cinema)
Day C: Szentendre, Open Air museum
Day D: Cycling tour – Vác, Nagymaros
Day E: Boat trip, Esztergom, Visegrád
Day F: Programmes in the camp, sport, competition, cooking
23 of July going home.

EQUIPMENT: Ordinary personal clothes and hygienic equipments. Please also take your
student card, insurance, and appropriate clothing for trips, rain, heat and cold.
Should you have any special eating wishes please write it by all means!
We would also like you to prepare a short presentation (PPS for computer) about
your country so that the other participants could get some information about it.

COSTS: During the two weeks the participants spend in Hungary are going to get full
board at the host families and from Rotary. So all need is only to take pocket
money for Museums, cinema and other tickets, and for public transport we need
money too .

INSURANCE: Participants must have valid insurance policy.

English
CAMP LANGUAGE: On the www.facebook.com you find the members of
Hungarian Bridge 2006 – 2007 – 2008 – 2009 - 2010.