2026 RYLA District 5470 Initial Registration and Consent Forms
Register to attend the Rotary Youth Leadership Awards (RYLA) from June 12-15, 2026 at the Golden Bell Conference Center, Divide, CO. Please complete this form to begin your application.
Student Name
*
First Name
Last Name
Your preferred name or nickname
*
This will go on your nametag
Gender
*
What are you preferred pronouns?
*
These will go on your nametag
What is your t-shirt size?
*
S
M
L
XL
XXL
Student Email
*
Use a non-school event since you'll need to access RYLA information even when school is not in session.
Student Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Current Grade
*
Please Select
9th
10th
11th
High School
*
Dietary Preferences/Restrictions
*
Vegan
Vegetarian
Gluten Free
Kosher
None
Other
Parent/Legal Guardian Name
*
First Name
Last Name
Parent/Legal Guardian Phone Number
*
Please enter a valid phone number.
Parent/Legal Guardian Email
*
example@example.com
Rotary Club Name
*
Rotary Club Contact
*
First Name
Last Name
Rotary Club Contact Email
*
example@example.com
Rotary Club Contact Phone Number
*
Please enter a valid phone number.
Explain in 100 words or less why you want to attend RYLA
*
0/100
What extracurricular activities/community service are you involved in?
*
Do you have an interact club at your school?
*
Yes
No
Are you a member of your school's Interact Club?
*
Yes
No
N/A
Interact Club Advisor's Name
First Name (or N/A)
Last Name (or N/A)
Interact Club Advisor's Email
Put N/A if you don't have an Interact Club
Back
Next
Medical and Emergency Information
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Relationship to Student
*
Emergency Contact Email
*
example@example.com
Date of Last Tetanus Immunization
-
Month
-
Day
Year
Date
Disability, chronic, or recurring illnesses
Current medications (please include dose and frequency)
Allergies to medicines, food, insect stings, or other factors
Please include what happens during this allergic reaction (e.g. lips swell)
Any other health conditions we need to be aware of
Do you have health insurance?
Yes
No
Insurance
Add N/A if no insurance
Policy Number
Add N/A if no insurance
Group Number (if applicable)
Consent for emergency medical treatment
The undersigned parents or legal guardians accept the responsibility of any cost involved in treatment or examination. The undersigned consent to emergency medical aid, treatment, necessary transportation, x-rays, routine tests, etc.
Student Name
*
First Name
Last Name
Student Signature
*
Parent/Legal Guardian Name
*
First Name
Last Name
Parent or Legal Guardian Signature
*
Back
Next
Waiver of Claims for Health Care Costs
ONLY COMPLETE THIS SECTION IF YOUR FAMILY DOES NOT HAVE ANY MEDICAL INSURANCE. The undersigned parents/legal guardians acknowledge that we do not have health insurance in effect for our child, and hereby agree to indemnify and hold harmless Rotary International, Rotary District 5470 and their RYLA designates from any and all health care costs that might be incurred on behalf of our child while attending or participating in the RYLA program and all activities related thereto.
Parent/Legal Guardian Name
First Name
Last Name
Student Name
First Name
Last Name
Parent/Legal Guardian Signature
Back
Next
RYLA Waiver and Release of Liability
Student Name
First Name
Last Name
Student Signature
*
Parent/Legal Guardian Name
First Name
Last Name
Parent/Legal Guardian Signature
*
Back
Next
Media Consent Form
Rotary District 5470 RYLA would like to share photos, videos and experiences of the campers on social media, to include Facebook (@RYLA Rotary District 5470) and Instagram (@rylad5470). We require parental approval for participants to be featured on social media, which will be monitored by RYLA administrators. We will post photos from the RYLA weekend and will invite members of the group to share their photos with the group. In addition, we would like permission to use some of these photos and videos in future promotional brochures, on the Rotary website and at conferences. This consent shall continue forever unless revoked in writing.
I hereby give consent to Rotary District 5470 RYLA to use my name and/or photograph in brochures, pamphlets, posters, articles, letters and/or news releases for magazines, newspapers, mailings, radio, TV, videotapes, social media, Rotary website and other audio/visual media. In granting this consent, I know that it will be used in the best interests of Rotary District 5470 RYLA and the individuals it serves as well as in my best interest.
Student Name
First Name
Last Name
Student Signature
Parent/Legal Guardian Name
First Name
Last Name
Parent/Legal Guardian Signature
Back
Next
RYLA Code of Conduct
I have reviewed and agree to the above RYLA Code of Conduct
Student Name
First Name
Last Name
Student Signature
*
Parent/Legal Guardian Name
First Name
Last Name
Parent/Legal Guardian Signature
*
Back
Next
Packing List
Please review the below packing list. It will be included in your email confirmation.
Back
Next
Student Personality Test
We ask students to take a quick personality test before RYLA to help build mixed groups and team cohesion. Please follow the instructions on the below PDF.
Please list your basic style, exactly as listed in the personality test.
*
Back
Next
Please follow us on Instagram!
Continue
Continue
Should be Empty: