Change of address online form, for Students placed in the United States, (a requirement of the U S Department of State)

This form must be submitted electronically. Printing or faxing will not be accepted.

*Student. FAMILY Name as shown on the application or guarantee form (not the host family name):
*Student First Name:
*This form prepared by:
*Date moved to New Host Family: (mm/dd/YYYY)
*Hosted in Rotary District Number:
*Host Rotary Club Name:
Student Email Address:
Certificate of Eligibility		*Date of Entry (Arrival) to US:
Previous Host Family Information (Student is moving From)
*Previous Host Family Name: (first & last name please)
*Previous Address:
*Previous City:
New Host Family Information (Student is moving to)
*New Host Family Name: (first & last name please)
New Host Family Email:
*New Address:
*New City:
*New State:		*New ZIP:
*New Phone:
*This is my:		host family
Did you change Schools: Yes No
If yes, contact your District Chair or Inbound coordinator.
		*Enter Word: