RYLA Application 2024-25

RYLA Application District 6440 2024-2025
- Applicant Name*
- Applicant Cell Phone Number*
- Applicant Email*
- Age*
- Gender*
- Applicant Home Address*
- Session*
- Would you be willing and able to switch weekends to insure your attendance?*
  
  YesNo
- Has a Rotary Club agreed to sponsor you?*
  
  YesNo
- If yes, which Rotary Club?
- Rotary Club Contact Name
  
  First NameLast Name
- Rotary Club contact E-mail
- High School*
- Grade in School*
- School Counselor/Representative*
- School Counselor/Representative's Email*
- What leadership positions have you held, either in or outside of school? Give the group's or organization's name, positions held, and dates.*
- Write a a short essay, no more than 500 words, on the importance of youth leadership in society.*
- Parent / Guardian Name*
- Parent/Guardian Cell Phone Number*
- Parent / Guardian E-mail*
- Emergency Contact's Name*
  
  First NameLast Name
- Relationship*
- Emergency Contact Cell Phone Number*
- Emergency Contact Alternate Phone
- Does the applicant have any allergies, chronic illness, or medical conditions? If yes, please describe.*
- Is the applicant prescribed an inhaler? If yes, please explain any instructions.*
- Student Agreement
  
  If I am selected to attend Rotary Youth Leadership Awards (RYLA), I agree to abide by all rules and regulations established by the sponsors, and I will strive to contribute my best effort toward the success of the program.
- When you submit this form:
  
  1. An email will be sent to your Parent / Guardian at the address you provided, for them to grant permission for you to attend RYLA, and to consent to certain waivers and releases.
  
  2. An email will be sent to your School Representative at the address you provided, for them to submit a recommendation for you to attend RYLA.
  
  You will be informed via email when each has provided the information, and when your application is complete.
  
  If you've provided the name of a sponsoring Rotary Club, they will also receive a copy of your application.
  
  Questions? Contact Sean Nelson, RYLA District Chairman, at 630-688-5165, or via email at ryla@rotary6440.org.
- Student Name*
- Student Signature Date*
  
  MonthDayYear
- Student Signature*
  
  Clear
  Sign with mouse or on touchscreen.
- Informed Consent and Acknowledgement
  
  As Parent and/or Guardian of the named student, I hereby give my approval for this child’s participation in any and all activities prepared by RYLA during the selected camp. In exchange for the acceptance of said child’s candidacy by RYLA, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Rotary District 6440 and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.
  
  In case of injury to said child, I hereby waive all claims against Rotary District 6440 including all counselors and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.
- Medical Release and Authorization
  
  As Parent and/or Guardian of the named student, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.
  
  Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named student. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.
  
  Permission is also granted to Rotary District 6440 and its affiliates including Directors, and Counselors to provide the needed emergency treatment prior to the child’s admission to the medical facility.
  
  Release authorized on the dates and/or duration of the registered event.
  
  This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
- Photo / Image Release
  
  As Parent and/or Guardian of the named student, I authorize Rotary District 6440 or its officers, employees, or agents, to record this child's images or likenesses in the form of photographs, audio, video, or any other medium, and to use, reproduce, modify, distribute, or publicly exhibit such recordings, in whole or in part, for any purpose. Further, I consent to the use of the child's name, voice, or biographical material in connection with any such recording.
- Approved By: Parent or Guardian Name*
- Parent/Guardian email*
  example@example.com
- Parent or Guardian Signature Date*
  
  MonthDayYear
- Parent/Guardian Cell Phone *
  Please enter a valid phone number.
- Parent or Guardian Signature*
  
  Clear
  Sign with mouse or on touchscreen.
- I recommend the above student and understand that, if selected, this student will attend one of the three Rotary Youth Leadership Awards (RYLA) conferences held at Camp Edwards in East Troy, WI. The Conference will begin on Thursday evening and continue through Sunday afternoon. The dates for this year's Conferences are March 6-9, 2025; or April 3 to 6, 2025.
- Approved By: Authorized School Representative *
- School Representative Title*
- School Representative Signature Date*
  
  MonthDayYear
- School Representative email*
  example@example.com
- Authorized School Representative Signature*
  
  Clear
  Sign with mouse or on touchscreen.
- Should be Empty:

RYLA Application District 6440 2024-2025