Event Registration Form

Event Information

Rotary Youth Leadership Awards (RYLA) is Rotary International’s outdoor leadership retreat for high school students. Sophomores, juniors, and seniors are invited to attend a weekend-long event with peers from along the North Shore of MA, where you'll cultivate life and leadership skills including goal setting, cultural understanding, problem solving, communication, public speaking, networking, community building, team building and more!
Event Date: May 12–14, 2023

Event Time: Friday 3pm – Sunday 2pm

Event Address: Camp Rotary – 372 Ipswich Rd, Boxford, MA

PLEASE NOTE: There is a a $25 application fee, payable by credit/debit card at the end of this form. If this amount is an issue for you or your family, please contact Christina Harris at christina@partnerwithchoice.com or your local Rotary club before completing this form.

Except for the $25 application fee, the full cost of the RYLA weekend will be paid by a sponsoring Rotary Club. If the student does not attend the weekend and does not provide at least 72 hours advance notice of their non-attendance, the RYLA program would appreciate a $100 donation to offset the non-recoverable costs.
Attendee Information

This page should be completed by the student. Please review the form, first, to make sure you have the information you need to complete it.
Student Name*

First NameLast Name
Preferred Name
Student Email*
example@example.com
Student Phone Number*
Preferred method of communication*

EmailText messagePhone call
Student Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
High School*
Student Grade*
Student Age*
Student Gender/Pronouns*

Female (she/her)Male (he/him)Non-binary (they/them)Other
Student T-Shirt Size*
How did you hear about RYLA?*

My guidance counselorA teacherA past RYLA participantA flyer at schoolMy parent/guardianThrough my local Rotary ClubInteractOther
Your sponsoring Rotary Club, if known
Don't guess! Ask the person who recommended you for RYLA.
Share an example of how your concept of leadership has played out in your life*
It does not have to be more than a paragraph or two.
The following sections should be completed by a parent or guardian.
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Relationship to Student*
Emergency Contact Phone*
Please enter a valid phone number.
Medical Information

If selected and able to attend RYLA, this information will be provided to our trained medical staff, who will be on-site at Camp Rotary for the duration of the RYLA, and this information will be in their possession at all times. A parent or guardian must complete this section, and it is important that the information is complete and accurate.
Health Insurance Provider*
Health Insurance Group/Policy Number*
Health Insurance Policy Subscriber Name*
Usually, a parent or guardian
Please list your student's allergies, if any
Please list and explain any health conditions, physical limitations, or any special considerations of which we should be aware
Please list all medications (prescription and over-the-counter) that your student will bring to RYLA. Include as-needed and emergency medications. Please use a separate line for each medication, and include medication name (as labeled), dosage, and when they take it (e.g., "with lunch" or "at bedtime").
IMPORTANT: All medications must be in the original container. Medications will be administered by medical staff, and must be given to the staff member at registration. If your student must carry emergency medication (such as an inhaler) and may self-administer, please note.
Is there anything else that we should know about your student?
I understand that the effectiveness of this program for my child and the other attendees depends on my child's ability to be at Camp Rotary continuously from 3pm on Friday until 4pm on Sunday, to participate in programmed activities (including outdoor activities and activities requiring a moderate amount of physical exertion), and to follow camp rules in a manner appropriate and consistent with the values and guidelines of my school district.I understand that RYLA representatives may take photographs, videotape, or digital recordings of my child over the course of the weekend, and I agree that RYLA and Rotary District 7930 may use such media, with or without my child’s name, for any lawful purpose including publicity, illustration, advertising, and web content.I recognize that COVID protocols will be in place. We plan to host a mask-free event but will encourage/require masks, if COVID infection rates increase. Masks, hand sanitizer, and testing kits will be available during RYLA weekend. As always, if an attendee is exhibiting cold-like symptoms prior to RYLA weekend, we ask that you test before attending. If you need to cancel because of COVID, please contact Christina Harris at 978-270-6706 as soon as possible.
Parent/Guardian Signature*

Powered by Jotform SignClear

Payment

RYLA Registration FeeA $25 fee is required with your application for RYLA. Please complete the form below.

$25.00

Enter coupon

Credit/Debit Card

Should be Empty:

Event Information

Attendee Information

Emergency Contact Information

Medical Information

Credit/Debit Card