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

For questions or information on our student travel program
contact Sheila at 860-886-0511 x108 image
Full legal name as it appears on your passport (no nicknames please):
* Indicates required fields
* First Name     
* Last Name     
* Email     
Address  
* City  
State
* Country
Postal Code  
Phone  
Fax  
Birthday


 
Age  
Sex
 
  Exchange Information
Home District Number  
   
  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  
 
   
 You must select a payment option to continue your registration.   
Payment Option     
 If paying by check please mail your check to the following address:

BokoffKaplan Travel
456 West Main Street
Norwich, CT. 06360
Attn: Sheila