2025 RYLA Chaperone Application

2025 RYLA Chaperone Application
Name*

First NameLast Name
Name of Sponsoring Club*
Select One*

RotarianSchool SponsorOther
Name of School*
Type NA if school unknown
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Cell Phone Number*
Please enter a valid phone number.
Name of Emergency Contact (someone who will not be with you at RYLA)*

First NameLast Name
Emergency Contact Relationship*
Emergency Phone Number*
Please enter a valid phone number.
Please select all current certifications or qualifications*

First AidCPRMDNurseOther (list below)None
Please provide additional information on any current medical certifications or qualifications*
Type "None" if None
T-Shirt Size (unisex)*
Occupancy (for double occupancy, please include name of roommate)*

Single Occupancy $325Double Occupancy $225
Name of Roommate * Include if selected Double Occupancy

First NameLast Name
Gender*

FemaleMale
Dietary Restrictions (select all that apply)*

Gluten-FreePorkPeanutOtherNone
Please explain any food allergies*
Type "none" if none
Have you experienced any of the following (select all that apply)*

shmaEating DisordersDiabetesFainting spellsBleeding disordersSeizures/ConvulsionsNon-food allergiesAttention disorders (ADHD)Wears contactsBehaviorOtherNone of the above
Please describe any conditions you checked*
Have you volunteered as a chaperone in the past*

YesNo
Standards of Behavior for RYLA Chaperones

Since RYLA is sponsored at the Inn at Virginia Tech and Skelton Conference Center, all volunteers must sign the Virginia Tech Standards of Behavior. The form can be found here. Please print and submit.
Standards of Behavior Form

Cancelof
How did you hear about RYLA*
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. Once your application has been approved, we will be sending you information to complete your background check. The club will be charged $9.50 for each background check; you should be notified no later than Nov. 1st of this process.
Should be Empty:

2025 RYLA Chaperone Application

RYLA Chaperone Participation

Payment