RYLA 2025 Participation Form

Student Registration Form

Fill out the form carefully for registration. Please contact office@rotary7620.org with any questions.
Student Name*

First NameMiddle NameLast Name
Nickname (the name the student would like to be called, if different than first name):
Birth Date*

MonthDayYear
Gender*
T-shirt Size:*
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 your HS has a interact club, are you a part of it?
Name of sponsoring Rotary Club:*
Name of sponsoring Rotary Club:*
Did this student previously attend District 7620's RYLA? (Please note, in order to give as many students as possible the opportunity to attend RYLA, we cannot usually accommodate repeat participants. If you are a RYLA alum who is interested in participating as an assistant group leader, please contact office@rotary7620.org).*
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
If you have any questions or need any assistance, please contact office@rotary7620.org
Should be Empty:

Student Registration Form

Parent/ Guardian Information

Emergency Contact Information:

Health Information

Waivers and Code of Conduct

https://app.box.com/s/vfiok0gz4kd9r4ci9441yazyvw6jdzms https://app.box.com/s/1e9u2d2j5y1rmmfjuvoums0tovvx8jhl