Leadership Camp Application
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Your First Name
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Last Name
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School
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Grade in Sept 2012
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- Student
- Jnr Chap
- Snr Chap
I am applying as:
Students are currently in a High School and must be preapproved by their school or their Interact club if applicable
Jr Chaps must have attended a previous Camp.
Snr Chaps are usually members of Rotary but may also be teachers or any adult.
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Are you now or will you be a member of your school's Rotary Interact Club?
- yes
- no
Member of Interact ?
On Club Executive ?
Your Interact Club or School Advisor
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Have you been involved in any other Rotary activities such as Camp Enterprise
or applied for Youth Exchange or .....?
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Age in Sept 2012
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Birthdate (YYYY/MM/DD)
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male
female
gender
Sponsoring Rotary Club
Parents' Names
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Home Address
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City
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Postal Code
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Telephone
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Email Address
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Family Doctor
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Dr Phone No
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School Leadership Avtivities
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Extracurricular Activities
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Hobbies
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Do you have a CGI certification?
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Assess your Swimming Experience and Expertise,(0 cannot swim - 5 Lifeguard certification)
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Assess your Canoeing Experience and Expertise, (0= never canoed, 5=expert)
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What do you want to achieve from the Camp?
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Any Special information such as Allegies, religious special needs or food conditions?
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Indicates Response Required
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