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Student Monthly Report

If you are a human and are seeing this field, please leave it blank.

Please provide the following information monthly. Be frank in your responses and tell us how it really is. If we are not aware of a concern/problem, we can not help you. Tell us and we will give you the support you need. Do a computer fill-in, click on submit and the report will be e-mailed to your Country Contact. Information will be kept confidential within the Youth Exchange Committee.

Your Name

Your Email

Phone

Host family phone

Host family address

City/state/zip

Country

Is this a change of host families?

Relationships

Please tell us how you feel about your relationship with each of the following:

Please tell us about any that you feel are poor or unsatisfactory:

Do you regularly receive your monthly allowance?:

If so, how much? (US)

How often do you attend your Rotary Club meetings?

weekly
monthly
don't attend

Have you attended any other Rotary functions in the past month?

Have you been entertained by any Rotary members?

Yes
No
Option 3

Speak at a meeting?

Yes
No
Option 3

Name of Host Club:

Name Counselor:

Counselor's email:

Counselor's phone#

Counselor's Address:

Host often do you meet with your counselor:

Who takes the initiative:

Do you feel your being listened to?

School's name

Courses:

School hours:

Days absent:

Holidays off:

Days skipped:

Days sick:

What school & community activities are you involved in (sports, extracurricular)?

Tell about any special activities or events that you've been involved in since the last report.

How do you feel about life as an exchange student in a different culture? What are your challenges?

Are there any concerns, questions, problems we can help you with or that you just want to share?