Student Travel Request Form

This form must be completed every time you wish to travel for stays within our District or for travel involving overnight stays outside our District.

You must not presume that you may automatically travel – youmust receive written permission from your country coordinator.

Student Name      Student email address      Host Rotary Club      Current Host Parents Name      

Address      Phone Number(s)      

Host Parent's Agreement Signature

Club President's Agreement Signature

Host Club Counsellor's Agreement Signature

Host Counsellor's phone number      Travelling with - School/Friends/Family      Travelling to - Place/State      Reason for Travel - Visit Friends/Holiday/School      Commencement date of travel      Return date of travel      Mode of Travel - Car/Bus/Train/Plane      

Flight Details      Where Staying: Home/Resort/Hotel      

Contact Numbers      

Country Coordinator's Approval Name      

Signature

Date