Bokoff-Kaplan Rotary Youth Exchange Program
Student Registration Form.
Complete the following form.

For questions or information on our student travel program
contact Theresa Bryan at 860-886-0511 x106 image
Full legal name as it appears on your passport (no nicknames please):
* Indicates required fields
* First Name     
* Middle Name     
* Last Name     
* Email     
Address  
* City  
State
* Country
Postal Code  
Phone  
Fax  
Birthday


 
Age  
Sex
 
  Exchange Information
Home District Number (In USA)  
   
  Country you are traveling to 
Host Country
 
  Fathers Information
Father Name  
Father Email  
Father Phone  
Father Fax  
 
  Mothers Information
Mother Name  
Mother Email  
Mother Phone  
Mother Fax  
 
Type the first 3 letters of the city closest to your home,
wait a few seconds then select the closest airport from the list.
  
Airport 1  
Airport 2  
Airport 3  
 
Do you have a valid passport?


 
   
 You must select a payment option to continue your registration.   
Payment Option     
 If paying by check please mail your check to the following address:

Tzell Park Avenue
456 West Main Street
Norwich, CT. 06360
Attn: Theresa Bryan

The ability to pay through PayPal will be coming soon.