RYLA 2027 - Student Registration
Select your sponsoring club
Please Select
Aggieland
Angelina-Lufkin
Beaumont
Beaumont-Spindletop
Bridge City-Orangefield
Bryan
Center
Cleveland
College Station
Conroe
Crockett
Dayton
Dickinson
East Montgomery County
Fredonia
Friendswood
Galveston
Galveston Island
Hardin
Huntsville
Lake Conroe
League City
Liberty
Livingston
Lonestar EClub
Lufkin
Magnolia
Nacogdoches
Nederland
Orange
Downtown Palestine
Palestine
Port Arthur
Port Neches-Groves
Rusk
San Augustine
Texas City
The Mainland (LaMarque,TX)
The Woodlands
Vidor
Woodville
Re-type Club name to confirm
High School Name
Type of School
Please Select
Public
Private
Home
Other
Gender
Name
First Name
Last Name
Preferred First Name for ID Badge (do you go by an abbreviated or middle name?)
Email
example@example.com
Preferred - Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Mobile Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian
First Name
Last Name
Parent/Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email (required for medical release purposes)
example@example.com
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
T-Shirt Size
Are you a member of Interact
Please Select
Yes
No
Dietary Restrictions
Be aware not all food preferences can be accommodated.
I do not have any scheduling conflicts for January 8-10, 2027 and will arrive on time and not leave the conference property during the event.
*
Please Select
True
False
I will attend all functions and participate with my assigned teams.
*
Please Select
True
False
I understand that cell phone use during sessions and activities is prohibited (except for camera photo purposes). Cell phones can be confiscated by an adult advisor and returned at the close of the conference if the participant is not giving their full attention to the speaker or facilitator.
*
Please Select
True
False
I will be respectful to speakers (talking or texting during presentations may be perceived as being disrespectful)
*
Please Select
True
False
I understand that verbal abuse, physical abuse, harassment, hazing (as defined by the Texas Legislature), and malicious or harmful pranks will not be tolerated.
*
Please Select
True
False
I will respect and observe conference and facility rules of the Pineywoods Baptist Encampment and not cause damage to the property. I will take care using any recreational equipment and will wear appropriate safety gear as directed.
*
Please Select
True
False
I understand that bringing or using vaping devices, alcohol, tobacco, illegal drugs or weapons is strictly prohibited.
*
Please Select
True
False
I understand that male participants are not allowed in female rooms and female participants are not allowed in male rooms at any time, and that I must stay in my assigned cabin after "Lights Out" until morning.
*
Please Select
True
False
I understand that failure to follow the rules makes me subject to immediate expulsion, which will result in a phone call to my parent/guardian for them to come get me from camp.
*
Please Select
True
False
List and explain any health conditions or physical limitations of participant (e.g. asthma, recent injuries limiting mobility, crutches, etc.):
Participant has known allergies.
*
Please Select
Yes
No
List allergies, if any:
Participant needs medications administered while attending RYLA (prescription and over the counter). 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 WITH ANY SPECIAL DISPENSING GUIDELINES.
*
Please Select
True
False
Medication Name #1 | Dosage | Frequency (e.g. with lunch, at bedtime, as needed)
Medication Name #2 | Dosage | Frequency (e.g. with lunch, at bedtime, as needed)
Medication Name #3 | Dosage | Frequency (e.g. with lunch, at bedtime, as needed)
Please enter name and phone number for the Primary/General Practitioner and insurance information.
*
The remainder of this RYLA registration form is to be completed by the participant's parent or legal guardian. It will require a signature.
*
Yes, I understand.
I understand that RELEASEES will not be responsible for any medical costs associated with an injury sustained by the participant.
*
Please Select
True
False
The participant and I further agree to become familiar with the rules and regulations of the camp and program concerning student conduct and not to violate said rules of any directive or instruction made by the person or persons in charge of set activity and that I will further assume the complete risk of any activity done in violation of any rule or directive or instruction.
*
Please Select
True
False
I also understand that I should and am urged by RELEASEES to obtain adequate health and accident insurance to cover any personal injury to the participant that may be sustained during the activity or the transportation to and from said activity. POSSIBLE INJURIES THAT MAY OCCUR- There are risks involved when participating in the following activities offered - the Challenge Course. The proposed activity provided by the Challenge Course requires participation and physical exercises which are, by their nature, physically demanding and may be performed from ground level and up to heights of 50 feet. Many of the activities will challenge the participant, and cause surges in blood pressure and respiration and pulse rates. It is imperative that the participant is free of any heart-related diseases. Therefore, all participants must be free of medical, psychological or physical conditions that might create undue risks to themselves or any others that depend on them.
*
Please Select
True
False
I have reviewed the above information and am aware of the risks involved in participating in the Challenge Course activities and the possible injuries that may occur. The participant freely and voluntarily agrees to participate in the activity listed herein. In signing this release, I acknowledge and represent that I have read the foregoing waiver of liability and hold harmless agreement, understand it and sign voluntarily as my own free act and deed; no oral representation, statements or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute this release for full, adequate, and complete consideration fully intended to be bound by same. Also, I understand that all rules and regulations for the conference/ camp/ event will be enforced and any violation by the participant will result in a collect call to the parent or legal guardian with a possible request to come and pick up the participant.
*
Please Select
True
False
Signature of Parent or Legal Guardian --By signing my name on this Waiver of Liability, I acknowledge that I have fully read and reviewed this waiver of liability and voluntarily agree to be bound by the provision and terms set forth.
*
Name of Parent or Legal Guardian Signing Waiver of Liabilty
*
First Name
Last Name
Signature of Parent or Legal Guardian
*
Name of Parent or Legal Guardian Signing Waiver of Liabilty for images and likeness
*
First Name
Last Name
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