2025 Event Registration Form

Important update as of April 11th - We have hit our maximum numbers for attendance at RYLA. Your application will be wait-listed. We frequently have students drop out, so you may still be able to join us! You will be notified by your supporting Rotary Club if you are able to attend. Thank you so much for your interest in RYLA!!
Event Information

Rotary Youth Leadership Awards (RYLA) is Rotary International’s outdoor leadership retreat for high school students. Sophomores and juniors are invited to attend a weekend-long event, where you'll cultivate life and leadership skills including goal setting, cultural understanding, problem solving, communication, public speaking, community building, team building and more!
Event Date: May 16–18, 2025

(NOTE: commitment for the entire weekend is required. Please check your schedule carefully)

Event Time: Friday 3pm – Sunday 3pm

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 $150 donation to offset some of 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 at the time of RYLA*
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 flyer at schoolMy parent/guardianThrough my local Rotary ClubInteractA past RYLA participant: Name__________________Other
Are you a member of your high school's Interact Club?

YesNo
Your sponsoring Rotary Club, if known
Hint - 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.
We would like to get to know you a little better. Please complete the following:
At a party, do you

interact with many, even strangersinteract with a few good friends
Do you think of yourself as

outgoingprivate
Are you the kind of person who is

rather talkativerather quiet and reserved
We would love to see your smiling face before RYLA - it's not required, but if you would like to upload a photo of yourself - we'd love to see it!
File Upload

Cancelof
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/sensitivities (including food), 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"). We will need a signed order form to distribute medication (by a Doctor, nurse or physicians assistant). Please send the form to RYLA District Chair, Christina Harris, Choice Graphics, 140 Central Street, Rowley, MA 01969 or bring to the RYLA weekend.
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 3pm 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 Districts 7930 & 7950 may use such media, with or without my child’s name, for any lawful purpose including publicity, illustration, advertising, and web content.The undersigned agrees and does hereby release from liability and indemnifies and holds harmless Rotary Districts 7930 & 7950, member Rotary Clubs, and Rotarians and non-Rotarians participating in the RYLA program. This release is for any and all liability for personal injury (including death) and property losses or damage occasioned by, or in connection with any activity or accommodations for this event.All health information provided by me for RYLA is correct and accurate to the best of my knowledge. I authorize trained medical staff to assist my student with his/her medications my student’s healthcare provider or I have directed, if needed. In addition, in the event of accident or sudden illness while at Camp Rotary, I authorize RYLA personnel to have my student taken to the nearest hospital and authorize treatment as maybe deemed necessary in an emergency for the health of the student. In the event physician(s), parent(s), or other persons designated by the parent cannot be contacted, RYLA personnel are hereby authorized to take whatever action is deemed necessary in their judgment for the health of the student.
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

We would like to get to know you a little better. Please complete the following:

Emergency Contact Information

Medical Information

Credit/Debit Card