Clone of 2025 Event Registration Form 7950

Event Date: May 15–17, 2026

(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

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 ask for a $150 donation to offset some of the non-recoverable costs.

If you have any questions, please reach out to Lew Gordon at lew.gordon77@gmail.com or (401) 447-0619.

Student Name

First NameLast Name

Preferred Name

Student Email

example@example.com

Student Phone Number

Format: (000) 000-0000.

Preferred method of communication

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

Other

Student T-Shirt Size

How did you learn about RYLA?

Are you a member of an Interact Club?

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.

At a party, do you

Do you think of yourself as

Are you the kind of person who is

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

The following sections should be completed by a parent or guardian.

Emergency Contact Name

First NameLast Name

Relationship to Student

Emergency Contact Phone

Please enter a valid phone number.Format: (000) 000-0000.

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.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

Important update as of April 13th

Event Information - D7950

Attendee Information

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

Emergency Contact Information

Medical Information