RYLA 2024 Participation Form

Student Registration Form

Fill out the form carefully for registration
Student Name

First NameMiddle NameLast Name
Nick Name:
Birth Date

MonthDayYear
Gender
T-shirt Size:*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student E-mail
example@example.com
Mobile Number
Phone Number
Work Number
High School
Grade:
If you HS has a interact club, are you a part of it?
Name of sponsoring Rotary Club:
Parent/ Guardian Information
Parent Name:

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Optional 2nd Parent Information:
Emergency Contact Information:

Emergency contact must be available the weekend of RYLA
Name

First NameLast Name
Relationship to Student:
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Health Information
My Son/Daughter/Ward the aforementioned delegate, has no physical, mental, or communicable condition that will interfere with his/her participation in this RYLA program?

AgreeDisagree
List all dietary restrictions:
List all allergies:
Please share any other health comments or concerns:
Waivers and Code of Conduct

Please Print the following, sign, and upload: Copy & Paste the link in your URL
https://app.box.com/s/vfiok0gz4kd9r4ci9441yazyvw6jdzms https://app.box.com/s/1e9u2d2j5y1rmmfjuvoums0tovvx8jhl
Upload the RYLA Code of Conduct here:

Cancelof
Upload the YMCA Waiver here:

Cancelof
Should be Empty:

Student Registration Form