RYLA Registration

Registration

Please note: Once your application is submitted you will receive a confirmation. The next communication you can expect from the RYLA team will be 1 week prior to the conference. For any additional information please contact your local Rotary Club.

Only Sophomores, Juniors and Seniors are able to apply.

RYLA REGISTRATION (FALL 2019)

Although not required, it will expedite the registration process if you have the email contact for the Rotary Club or sponsoring organization readily available prior to filling this application out. Rotary Clubs are asked to interview participants. Some do some do not. The cost is $275 to the sponsor.

RYLA is for 15 years of age or older, (High School Sophmores, Juniors and Seniors.) Although not required, it will expedite the registration process if you have the email contact for the Rotary Club or sponsoring organization readily available prior to filling this application out. Rotary Clubs may require an interview. The cost is $275 to the sponsor.
FIRST NAME*
LAST NAME*
DATE OF BIRTH*
GENDER*
AGE*
Please enter a number from 15 to 19.
FIRST NAME FOR YOUR NAME TAG*
This may not be changed after this form is submitted please make sure this is accurate.
HOME PHONE NUMBER*
CELL PHONE NUMBER*
YOUR PRIMARY EMAIL*
PARENTS EMAIL*
ADDRESS*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
SHIRT SIZE: This is included in your registration. No extra payment is required. However other items are available for purchase (not for profit)*
- S
- M
- L
- XL
- 2XL
- 3XL
Your High School*
Other (Please fill in your School Name):
GRADE*
EXPECTED GRADUATION DATE*
MM
DD
YYYY
Are you a member of an Interact Club?*
If YES, select the Interact Club of which you are a member.
CLUB MEMBERSHIP, SCHOOL SERVICE, CLUB SERVICE:*
WORK EXPERIENCE:*
PLEASE ATTACH RESUME (optional)
This is helpful if you are looking for sponsorship and are not in touch with a Rotary Club or Organization at this time.
HEALTH HISTORY & EMERGENCY TREATMENT AUTHORIZATION
INSURANCE COMPANY*
MEDICAL INSURANCE POLICY NUMBER*
NAME OF INSURED*
IN CASE OF EMERGENCY
CONTACT NAME*
First Last
Emergency Contact Phone Number #1
Emergency Contact Phone Number #1
CONTACT ADDRESS*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
RELATIONSHIP TO PARTICIPANT*
Taking any medication?*
- Yes
- No
ANY PRE-EXISTING INJURIES (ANKLES, KNEES BACK, ETC.) THAT MIGHT BE AGGRAVATED BY THIS EVENT?*
- YES, I have a pre-existing injury
- NO
ANY HEART PROBLEMS OR HEART MEDICATION?*
- YES, I have/have had heart complications
- NO
DO YOU HAVE HIGH BLOOD PRESSURE?*
- YES, I have/have had high blood pressure
- NO
DO YOU HAVE ANY ALLERGIES (FOOD, BEES OR INSECTS)?*
- YES, I have an allergy (or allergies)
- NO
IF YES TO ANY OF THE ABOVE, PLEASE GIVE DETAILS BELOW:*
IF NO PLEASE WRITE 'NONE'
ARE YOU A VEGETARIAN?*
- YES, I am a vegetarian
- NO
DIETARY RESTRICTIONS/FOOD ALLERGIES?*
- YES, I have a dietary restriction and/or food allergy
- NO
DETAILS
SPONSORSHIP / PAYMENT
Please Select Your Sponsoring Organization*
You must be sponsored to attend RYLA. This is usually but NOT limited to a Rotary club. Employers, businesses, foundations, and other organizations may also sponsor you for RYLA.
Contact Email Address for the Sponsoring Orgainization:*

IMPORTANT: Your registration package will be sent to this email address. This is to request sponsorship to the conference. Leaving this blank will delay your process. IT IS HIGHLY RECOMMENDED THAT YOU FOLLOW UP WITH AN EMAIL TO THIS INDIVIDUAL IN THE CHANCE THAT YOUR APPLICATION GOES INTO A SPAM FOLDER. IF THIS OCCURS PLEASE SEND AN EMAIL TO: d7980youthservices@gmail.com (Admin- under contacts on this website)
Please share the name of a RYLA facilitator that referred you to RYLA.
Leave this blank if this does not apply.
APPLICANT / PARENT (LEGAL GARDIAN) AGREEMENT (RYLA)
In consideration of the attendance of my child at the above named activity by Rotary International District 7980, and for allowing my child to participate in this activity, I do hereby release and discharge Rotary International District 7980 and all of its directors, agents, and volunteer adult leaders acting officially or otherwise from any and all claims, demands, actions, or causes of action on account of any injury sustained by my child during RYLA activities. I hereby authorize any director, volunteer adult leaders, or agent of Rotary International District 7980 to obtain emergency medical treatment for my child at any time during the RYLA activities. I understand that an attempt will be made to notify the parent(s)/guardian first. If the parent(s)/guardian are not available, the youth will be taken to the emergency room at the nearest hospital as circumstances may warrant. If any conduct of the participant warrants them to be excused from participation in the event, I assume all responsibility for disciplinary action and picking up my child upon being notified by the director, volunteer adult leader or agent of Rotary International District 7980. Should a medical issue, disciplinary action or other arise that requires my child’s dismissal from the conference, I agree to provide all necessary transportation. I hereby assign and grant to the Rotary International District 7980 the right and permission to use and publish, without limitation, the photographs/film/videotapes/electronic representations and/or sound recordings made of my child by Rotary International District 7980 and I hereby release Rotary International District 7980 from any and all liability from such use and publications. I authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution of said photographs/film/videotapes/electronic representations and/or sound recordings without limitation at the discretion of Rotary International District 7980. I, the undersigned, hereby acknowledge that I have read the foregoing, understand its contents, and have signed the same as my own free act and deed.
RYLA CONFERENCE RULES/EXPECTATIONS
As a participant attending the RYLA Conference you must agree to abide by the following:
1. You may not leave Camp Hazen at any time during the Conference except with permission from the RYLA Conference Directors & you will be accompanied by an adult volunteer - unless you are with your parent.
2. Cell phones are not permitted during the instructional sessions.
3. Possession or use of drugs, alcoholic beverages or other stimulants is strictly forbidden.
4. During sleep hours you must be in your designated area and may not leave after curfew. Male and female participants will have separate accommodations.
5. You must wear your nametag at all times.
6. You must attend all scheduled activities.
7. You must stay in the areas designated for Conference use. Any violation of the above regulations will constitute immediate dismissal from the conference.
AGREEMENT & SIGNITURES
I [the participant] have read and understand the rules for the RYLA conference. I agree to abide by these rules.*
Signature of Participant*
I agree that ALL the above information is correct. Furthermore I agree to the CAMP HAZEN'S RELEASE/WAIVER, RYLA'S RELEASE/WAIVER AND RYLA CONFERENCE RULES. I agree that the digital signature is equivalent to a signed signature. Please type your name as a signature.
Signature of Parent or Legal Gardian*
I agree that ALL the above information is correct. Furthermore I agree to the CAMP HAZEN'S RELEASE/WAIVER, RYLA'S RELEASE/WAIVER AND RYLA CONFERENCE RULES. I agree that the digital signature is equivalent to a signed signature. Please type your name as a signature.I agree to the above informed consent/liability release. I agree that the below digital signature is equivalent to a signed signature. Please type your name as a signature.

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Registration

RYLA REGISTRATION (FALL 2019)

HEALTH HISTORY & EMERGENCY TREATMENT AUTHORIZATION

IN CASE OF EMERGENCY

SPONSORSHIP / PAYMENT

APPLICANT / PARENT (LEGAL GARDIAN) AGREEMENT (RYLA)

RYLA CONFERENCE RULES/EXPECTATIONS

AGREEMENT & SIGNITURES