RYLA Chaperone Application
Name
*
First Name
Last Name
Name of Sponsoring Club
*
Please Select
Abingdon
Altavista
Amherst
Bedford
Blacksburg
Bluefield
Botetourt
Bridgewater
Bristol Morning, Va.-Tn.
Bristol, Va.-Tn.
Broadway-Timberville
Buena Vista
Chatham
Christiansburg-Blacksburg
Clarke County
Covington-Hot Springs
Danville
Danville-After Hours
Danville-Riverview
Elizabethton
Floyd County
Forest
Frederick County
Front Royal
Giles County
Glenvar
Greeneville
Greeneville-Morning
Harrisonburg
Harrisonburg-Massanutten
Hillsville
Johnson City
Johnson City Evening
Johnson City, TN Morning
Kingsport
Kingsport-Downtown
Kingsport-Sunrise
Lexington
Lexington Lunch
Lexington Sunrise
Luray
Lynchburg
Lynchburg-Morning
Marion
Marion-Morning
Martinsville-Henry County
Montgomery County
Mt. Jackson-Edinburg
Nelson County
New Market
Northern Shenandoah Valley
Pulaski
Radford (Noon)
Roanoke Valley (Roanoke)
Roanoke-Downtown
Rockingham County
Rocky Mount
Russell County
Salem
Scott County
Skyline Connections
Smith Mountain Lake
Staunton
Staunton-Augusta County
Strasburg
Stuart
Tazewell
The Blue Ridge – New Generations
Tri-Cities
Unicoi County
Warren County
Washington County
Waynesboro
Waynesboro-East Augusta County
Winchester
Woodstock
Wytheville
Select One
*
Rotarian
School Sponsor
Other
Name of School
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Cell Phone Number
*
Please enter a valid phone number.
T-Shirt Size (unisex)
*
Please Select
XS
S
M
L
XL
XXL
XXL
Occupancy (for double occupancy, please include name of roommate
*
Single Occupancy $325
Double Occupancy $225
Name of Roommate * Include if selected Double Occupancy
First Name
Last Name
Gender
*
Female
Male
Dietary Restrictions
*
Please Select
Gluten-Free
Pork
Peanut
Other
None
Background Checks
All chaperones are required to complete a Rotary online background check. This is regardless of whether you have already completed a background check through a school or other organization. The form can be completed online here - https://form.jotform.com/232613557265054
Have you applied for a background check?
*
Yes
No
How did you hear about RYLA
*
Please Select
District Email
Rotary International
Club
Friend
Other
RYLA Chaperone Participation
By submitting your RYLA Chaperone Application, you agree to participate in all RYLA activities throughout the weekend, complete room checks for assigned students, mentor and engage with students, ensure students abide by the student code of conduct, and agree to assist with any programming needs.
Payment
Once your application has been approved, your Rotary Club will be invoiced for the full amount.
Submit
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