RYLA 2022 Student/Camper application. Your local Rotary Club is pleased to present to you the opportunity to attend Rotary Youth Leadership Assembly, from April 29- May1, 2022 at Pali Retreat in Running Springs, California. Applications are due March 1, 2022. Please fill out this application form. Both the PARENT/GUARDIAN and the APPLICANT must review this application and both must sign this application to indicate agreement. If any question does not apply, please write "n.a." Your application is incomplete until we receive your signed medical release and liability waiver. The link to download the release and waiver is towards the end of this application form. Download the release and waiver, fill it out, sign it and email it to ryladistrict5280@gmail.com If your application is incomplete, we will contact you. Please make sure you are able to receive emails from ryladistrict5280@gmail.com. If you have any questions, please email ryladistrict5280@gmail.com RYLA will provide bus transportation to and from RYLA from locations throughout LA County. RYLA will notify the Parent/Guardian and the Camper of the PICK-UP TIME. It is the Parent's/Guardian's RESPONSIBILITY to take the camper to their pick-up location. At the end of RYLA, it is the Parent's/Guardian's RESPONSIBILITY to meet the camper at the return location. RYLA will notify the parent/guardian of the expected return arrival time. It is the Parent's/Guardian's RESPONSIBILITY to have the camper excused from school if necessary.

RYLA 2023 STUDENT APPLICATION

Your local Rotary Club is pleased to present to you the opportunity to attend Rotary Youth Leadership Assembly, from April 28-30, 2023 at Pali Retreat in Running Springs, California. Applications are due February 15, 2023. Please fill out this application form. Both the PARENT/GUARDIAN and the APPLICANT must review this application and both must sign this application to indicate agreement. If any question does not apply, please write "n.a.". Your application is incomplete until we receive this entirely filled out application with your guardian/parent's signature at the bottom. Please make sure you are able to receive emails from ryladistrict5280@gmail.com and direct any questions to this email address. RYLA will provide bus transportation to and from RYLA camp from locations throughout LA County. RYLA will notify the Parent/Guardian and the Camper of the PICK-UP TIME. It is the Parent's/Guardian's RESPONSIBILITY to take the camper to their pick-up location. At the end of RYLA, it is the Parent's/Guardian's RESPONSIBILITY to meet the camper at the return location. RYLA will let your child know when to notify the parent/guardian of the expected return arrival time. Each Parent/Guardian will have 30 minutes to pick up the camper at the designated location. It is the Parent's/Guardian's RESPONSIBILITY to have the camper excused from school if necessary.
Student's Last name*
Student's First name*
Preferred name (i.e. my name is Joshua, but I like Josh)
Gender Assigned at birth (if other than M/F, please identify in other)*

FemaleMaleOther
Gender ID (if chose other)
Preferred Pronouns

She/Her/HersHe/His/HimThey/ThemOther
Student's Street address*
City*
Zipcode*
Student's cellphone (enter as 555-888-9999)*
Student's email address*
Student's birthdate*

MonthDayYear
Student's current age*
Grade in High School*

FreshmanSophomoreJuniorSenior
High School*
Club or organization (e.g. Interact or name of group inviting you)*
Please choose your T-shirt size (sizing Unisex, ie Hanes Beefy T)*

XSSMLXLXXLOther
Bus pick up and return location (your RYLA bus)*

ChatsworthDowneyGlendaleHawthorneWest Hollywood/Pan Pacific ParkGardenaCulver City
Your Rotary sponsor club (if the club is not on this list, ask your sponsor or email us at ryladistrict5280@gmail.com)*

BellflowerBeverly HillsBurbank NoonBurbank SunriseCalabasasCarson Gardena DominguezColombo AmericanoComptonCrenshaw Park Hills HeightsCulver CityDistrict 5280D5280 Rotarians Fighting Human TraffickingDowntown LA (DTLA)DowneyEl SegundoGlendale NoonGlendale SunriseGranada HillsGreater Van NuysHawthorne LAX LennoxHermosa BeachHistoric FilipinotownHollywoodKoreatownLA 5LA CedarsNortheast LALatinos UnidosLawndaleLynwoodMalibuManhattan BeachMental Health & WellnessPacific PalisadesPalos Verdes PeninsulaPalos Verdes SunsetParamountPlaya Venice SunriseRancho ParkRedondo BeachRio Hondo VernonRotarians for Environmental ActionSan Fernando Valley EveningSan PedroSanta Clarita SunriseSanta Clarita ValleySouth Bay SunriseSouth GateSouthwest LAStudio City Sherman OaksThai TownTorrance Del AmoWest TorranceWestchesterWestwood VillageWilmingtonWilshireWoodland HillsOther
PARENT/GUARDIAN CONSENT: I hereby grant permission for my child to attend RYLA on April 29 to May 1, 2022 at Pali Retreat, Running Springs, CA. I understand that I will be notified of the PICK-UP TIME and that it is the PARENT'S/GUARDIAN'S RESPONSIBILITY to bring the camper to the designated pick-up location. I also understand that it is the PARENT'S/GUARDIAN'S RESPONSIBILITY to meet the camper at the return location. I also understand that it is the PARENT’S /GUARDIAN'S RESPONSIBILITY to have my child excused from school. NOTE: Rotary requires that for minors in the legal custody (NOT physical custody) of either parents or more than one legal guardian, both or all must sign this consent. The undersigned agrees that this document may be electronically signed through the use of any commercially available electronic signature software, which is selected by Rotary International District 5280 for use on this document, and which produces a confirmed signature delivered electronically to Rotary International District 5280. Parent/Guardian Name:*
Parent/Guardian's Full Home Address*
Primary Parent/Guardian's Email Address*
Primary Parent/Guardian's telephone*
Second Parent/Guardian's (if applicable)
Second Parent/Guardian's full address
Second Parent/Guardian's Email Address
Second Parent/Guardian's telephone
Primary Parent/Guardian's relationship to student*
If Parents/Guardians are not available during camp days, please indicate an alternate in case of emergency primary contact name (if this is one of the primary guardians, please indicate their information again)*
Emergency Primary Contact's relationship to student*
Emergency Primary Contact day AND night phone numbers*
Emergency Second Contact name*
Emergency Second Contact's relationship to camper*
Emergency Second Contact day and night phone numbers*
MINOR HEALTH HISTORY Please indicate if you have had or are prone to any of the following (all answers will remain strictly private). If you checked any of the boxes, please fill in other if your student currently has and when/if they will be cleared by doctor. Students must be clear of all communicable diseases prior to the camp beginning. Please indicate in "Other" if the affliction might prevent some physical activities at the camp:*

AsthmaBleeding and Clotting DisorderChicken PoxConvulsionsDiabetesEar InfectionEnuresis (Bedwetting)German MeaslesHeart Defects, DiseaseHypertensionMeaslesMononucleosisMumpsRheumatic FeverSleepwalkingPhysical disability (please clarify in Other)N/AOther
Allergies (if any of the below or one you have added require medication, and your student requires specific medication that is not in our OTC medical kit, please have your student present to the counselor on the bus in a quart size ziplock bag with your student's name, type of medication and dosage).*

HayfeverPoison IvyInsect StingsPenicillinOther Drugs (list directly below)N/AOther
Does your Child require any prescription medication of any sort including inhalers and epi pens while on the trip (if yes, please list in "other" below). Any medications of these sorts, should be presented to the counselor on the bus in a quart size ziplock bag with your student's name, type of medication an dosage.*

YesNoOther
For over the counter medications, please list any that the counselors and staff can NOT give your student (for example, ibuprofin, claritin, etc.)
Dates for MMR (Measles, Mumps, Rubella)*

MonthDayYear
Dates for DTP Series*

MonthDayYear
Dates for Polio OPV (Sabin)*

MonthDayYear
Date of last Tetanus vaccine (must be current, within 10 years)*

MonthDayYear
Student is Fully Vaccinated Against Covid-19

YesNo
Operations or serious injuries in the past 5 yrs (list dates)*
Disability or illness (if not covered in Minor Health History Above)*
Dietary modifications (e.g. vegetarian, celiac)*
Name of family Physician and phone numbers*
Name of dentist/orthodontist and phone numbers*
IMPORTANT: Please notify ROTARY ryladistrict5280@gmail.com if this student was exposed to a communicable disease (i.e. Covid-19, etc) within three weeks of attending RYLA. By signing below, I (parent/guardian) agree that the minor health history is correct to my knowledge, and the minor has permission to engage in all prescribed activities as noted by me on this health form. The undersigned agrees that this document may be electronically signed through the use of any commercially available electronic signature software, which is selected by Rotary International District 5280 for use on this document, and which produces a confirmed signature delivered electronically to Rotary International District 5280. Parent/Guardian signature:
Signature

Clear
ROTARY INTERNATIONAL DISTRICT 5280 AUTHORIZATION AND RELEASE FOR MEDICAL AND DENTAL TREATMENT The undersigned, as the parent or parents, or legal guardian or legal guardians, of the above-named minor (the “minor"), hereby authorize ROTARY INTERNATIONAL DISTRICT 5280 and its authorized directors and leaders (collectively "ROTARY") to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care (collectively "medical care") to be rendered to the minor under the general or special supervision and upon the advice of a physician or surgeon licensed under the laws of the State of California or other jurisdiction in which medical care is sought, and to consent to any x-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care (collectively "dental care") to be rendered to the minor by a dentist licensed under the laws of the State of California or other jurisdiction in which dental care is sought. For the purpose of medical care or dental care obtained in the State of California, this authorization is given pursuant to the provisions of Section 25.8 of the California Civil Code, as amended. For the purpose of medical care or dental care obtained outside of California, this authorization is given with the intent that any consent given pursuant to this authorization shall be the consent of each of the undersigned. It is understood that if time and circumstances reasonably permit, Rotary International District 5280 will endeavor, but is not required, to communicate with at least one of the undersigned prior to the rendering of medical care of dental care for which consent is given pursuant to this authorization. The undersigned understand and agree that Rotary International District 5280 and its delegated leaders and directors shall not be legally or financially liable for any claim rising from any medical care or dental care provided pursuant to this authorization. The undersigned hereby agree to indemnify and hold Rotary International District 5280 harmless from any claim made by or on behalf of said minor arising out of any medical care or dental care provided pursuant to this authorization. This authorization is given to Rotary International District 5280 for use in conjunction with any event operated by Rotary International District 5280, and shall be valid until revoked in writing by the undersigned or any of them. Parent/Guardian, please write your name below as confirmation of this waiver.
Signature

Clear
We do or do not have health insurance (if yes, under other add medical insurance company, policy number and expiration date)*

YesNoOther
ROTARY INTERNATIONAL DISTRICT 5280 RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT IN CONSIDERATION of being permitted to participate in any was in programs affiliated with (or for my child to participate) for any purpose, the undersigned for herself or himself and such participating child and any personal representatives, heirs, and next of kin, hereby acknowledges, agrees and represents that he or she has inspected and carefully considered such program. It is further warranted that participation in the program constitutes an acknowledgment that such program has been inspected and carefully considered and that the undersigned finds and accepts same as being safe and reasonably suited for the purpose of participation by the undersigned and such child.IN FURTHER CONSIDERATION OF BEING PERMITTED TO PARTICIPATE IN ANY WAY IN SUCH PROGRAMS, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING:1. THE UNDERSIGNED ON HER OR HIS BEHALF AND ON BEHALF OF SUCH CHILD, HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE Rotary International District 5280, its directors, officers, employees, and agents) hereinafter referred to as "releasees") from all liability to the undersigned, his personal representatives, heirs, and next of kin for any loss or damage, and any claim or demands therefore on account of injury or death to the undersigned or such child, or property damage, whether caused by the negligence of the releasees or otherwise while engaged in any activity related to such program affiliated with Rotary International District 5280. 2. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releasees and each of them from any loss, liability, damage or cost they may incur due to the participation of the undersigned or child of the undersigned whether caused by the negligence of the releasees or otherwise. 3. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE to the undersigned or child of the undersigned due to negligence of releasee or otherwise while engaged in any activity related to such program affiliated with Rotary International District 5280. 4. THE UNDERSIGNED HEREBY ASSUMES FULL COST OF TRANSPORTATION CHARGES to the undersigned or child of the undersigned for reasons of health, accident or failure to conform to rules established. We agree to accept full responsibility for and to pay for the cost of medical care, transportation and other incidental expenses. This permission slip also serves as a contract that the minor and parent(s) understand and agree to the guidelines. (See what to/not bring list)THE UNDERSIGNED further expressly agrees that the foregoing RELEASE, WAIVER AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE, WAIVER AND INDEMNITY AGREEMENT, and further agrees that no oral representations, statements or inducement apart from the foregoing written agreement have been made. The Rotary clubs are spending hundreds of dollars teaching your children leadership skills. If your child is signed up and cannot go, you must let us know before April 1, 2022. If you do not let us know before that date, you will be financially responsible to reimburse the Rotary club that sponsored your child. The undersigned agrees that this document may be electronically signed through the use of any commercially available electronic signature software, which is selected by Rotary International District 5280 for use on this document, and which produces a confirmed signature delivered electronically to Rotary International District 5280. Parent/Guardian to sign below as confirmation.
Signature

Clear
I UNDERSTAND IF CAMPER DOES NOT FOLLOW AGREED UPON RULES/BEHAVIOR, IT IS MY RESPONSIBILITY AS PARENT/GUARDIAN, TO COME AND PICK UP CAMPER AT MY OWN COST IF NOTIFIED BY RYLA CAMP DIRECTORS. Parent/Guardian to sign below as confirmation.
Signature

Clear
Parent/Guardian Signature here confirming student's attendance, medical/dental waiver, and liability waiver.*

Clear
As parent/guardian, I agree to allow our student to be photographed and or video taped as part of the activities at RYLA, the product of which may be used for promotional and marketing purposes for future camps and Rotary conferences.

YesNo
Parent/Guardian email address*
Should be Empty:

RYLA 2023 STUDENT APPLICATION

I UNDERSTAND IF CAMPER DOES NOT FOLLOW AGREED UPON RULES/BEHAVIOR, IT IS MY RESPONSIBILITY AS PARENT/GUARDIAN, TO COME AND PICK UP CAMPER AT MY OWN COST IF NOTIFIED BY RYLA CAMP DIRECTORS. Parent/Guardian to sign below as confirmation.