Interact Membership Application Form

I. General Information
Name:
Address: City: Zip:
Telephone # or Cell phone#:
Date of Birth: Grade
E- mail:

Please Write your Class Schedule below:

Period Class Teacher Room#
1
2
3
4
Indicate which lunch you have (Circle one): FIRST or SECOND

If needed, may members of Rotary be given your telephone number to notify you of club activities?
Circle: YES or NO

II. Time Commitment

Which OHS clubs have you joined this year? Indicate any office that you will be holding.

Do play any sports at OHS? Please list them.

Do you work after school? How many hours a week?

Do you have time and are you willing to support our projects? Active members give at least 4 hours of service
to Interact each month. Circle: YES or NO

III. Service
In your opinion how can Interact contribute to understanding and friendship between the people of different
countries and to the creation of international understanding within your own school and community?

In your opinion how can Interact serve your community and or school through specific projects?
 IV. Your Special Interests and Talents
What are you favorite subjects in school?

List any hobbies that you happen to enjoy.

List any languages other than your native language which you can speak, read or/and write.

What are your major occupational or career interests?

V. Roseville Rotary
Interact is sponsored by Roseville Rotary Club, which is a member of Rotary International. Do you understand
this relationship and will you cooperate with the Rotary Club as explained in the Interact Club constitution?
Circle: YES or NO

We appreciate your interest in the Interact Club. Please make every effort to attend our meetings and to
participate in our activities. Opportunities for service are endless. We need your talents, ideas and commitment!

Signed: Date:

Dear Interact member,

Interact has a club website, which includes club information, activities, weekly news, and roster. We will
be taking pictures of Interact activities and members. In order for your pictures to be posted on the Interact Club
web site, we need your permission and signature and your parent or guardian.

If you would like your picture posted on the website, have you parent sign below and bring it to Mrs. Muller’s
room, room 105 or to one of the Interact meetings as soon as possible. Thank you!
Andrewa Muller, Club Advisor

I give permission to the Interact Club to post my picture next to my name on the Interact Club web site. I
understand that my picture and name will be viewable by anybody who visits the website.
Member Signature
Date

I give permission to the Interact Club to post my child’s picture next to his/her name on the Interact Club
website. I understand that his/her picture and name will be viewable by anybody who visits the website.
Parent/ Guardian Signature
Date