Rotary Youth Leadership Awards Camp Application
Student Name
*
First Name
Last Name
Select
Male
Female
Birth Date
*
-
Month
-
Day
Year
Date
Current Grade
*
10th Grade
11th Grade
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Number
Please enter a valid phone number.
Student's Email
*
example@example.com
List your school and/or community activities and why you are applying for this award.
Parent's Phone
*
Please enter a valid phone number.
Parent's Email
*
example@example.com
Paren'ts Signature
*
By submiting this application, I give my child permission to apply for the Rotary Youth Leadership Award.
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