RYLA Student Participant Form

RYLA Participant Form
Dear Rotarians,

Please fill out the personal information for your selected RYLA participant(s).

(Note: If you have multiple students, you will need to submit a form for each student separately.)

We desire to have a diverse group of participants, so we encourage you to consider that in your selection process. Many times our men are not sponsored as often so please keep this in mind in your selection process. All participants selected should be mature, motivated, and interested in developing their leadership skills.

If you haven't yet, you also need to fill out the Rotary Club Sponsor Form.

This form is designated for the person your club chooses to be the liaison for RYLA. Once all required fields are completed, please click the “Submit” button below to receive your confirmation.

RYLA Participant Forms are due by March 31st.

Please note: Once this form is submitted, your selected participant will receive an email with further information from the RYLA Staff.
Student Name*

First NameLast Name
STUDENT INFORMATION
First Name Requested for Badge:*
Gender*
Birthdate:*

MonthDayYear
Date
Student E-mail*
example@example.com
Student Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
High School Attending:*
T-Shirt Size:*
Any Food Allergies / Considerations:*
Currently involved in an Interact Club?:*
PARENT / GUARDIAN INFORMATION
Parent/Guardian Name:*

First NameLast Name
Parent/Guardian Phone Number (To Be Used in Case of Emergency During Conference)*
Please enter a valid phone number.
Parent Email:*
example@example.com
SECONDARY EMERGENCY CONTACT
Secondary Emergency Contact:*

First NameLast Name
Phone Number*
Please enter a valid phone number.
ROTARIAN INFORMATION
Rotarian Name*

First NameLast Name
Rotarian Email*
example@example.com
Rotarian Phone Number*
Please enter a valid phone number.
Sponsoring Rotary Club*
Should be Empty:

RYLA Participant Form

STUDENT INFORMATION

PARENT / GUARDIAN INFORMATION

SECONDARY EMERGENCY CONTACT

ROTARIAN INFORMATION