Rotary District 7570
Rotary Youth Leadership Awards Seminar
Nomination Form

December 11-13, 2009 Virginia Tech

The _________________________ Rotary Club is accepting applications to attend the 2009 Rotary Youth Leadership Awards Seminar at the The Inn at Virginia Tech and Skelton Conference Center in Blacksburg, Virginia. The ________________________ Rotary Club will provide tuition for the seminar and transportation to and from the seminar for junior and/or senior students of ___________________________ High School/s. Applicants interested in attending this seminar must fill out this information sheet and participate in an interview with a member of the sponsoring Rotary Club. Interviews will take place the week of _________________________, and will be coordinated through your guidance office.

The sponsoring Rotary Club will pay seminar fees

For further information, please contact:

High School Contact______________________________________________

Telephone ______________________E-mail ______________________________

Rotary Club Contact ________________________ Telephone ____________________

Applicant Information Sheet:

Student's Name ________________________________________________
                                      (Last Name    First Name    Middle Initial)

Name of School ________________________________________________

Student's Address ______________________________________________

Student's Telephone Number _____________________________________

Student's Age ___________________     Student's Gender ___________

Student's Email Address _________________________________________

School Contact ________________________________________________
                                     (Name and Telephone Number)

High School Activities:

Community Activities:

Recognitions, Honors, and Awards: