STUDENT INFORMATION
Student Name:
First Name
Last Name
Nick Name:
Gender:
Please Select
Male
Female
Other
Date of Birth:
-
Month
-
Day
Year
Date
T-shirt Size:
S
M
L
XL
XXL
Other
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Phone Number:
-
Area Code
Phone Number
Email:
example@example.com
Highschool:
Grade:
10th
11th
12th
If your HS has an interact club, are you a member?
Yes
No
Name of Sponsoring Rotary Club:
PARENT/GUARDIAN INFORMATION
Parent Name:
First Name
Last Name
Phone Number:
-
Area Code
Phone Number
Email:
example@example.com
Optional 2nd Parent Information:
EMERGENCY CONTACT INFORMATION
Emergency contact must be available during the RYLA Weekend
Full Name:
First Name
Last Name
Relationship:
Sibling
Parent
Child
Friend
Other
Phone Number
-
Area Code
Phone Number
Email:
example@example.com
HEALTH INFORMATION
My son/daughter/ward, the aforementioned delegate, has no physical, mental, or communicable condition that will interfere with his/her participation in this RYLA program.
Agree
Please list any dietary restrictions:
Please list any allergies:
Please share any other health comments or concerns:
WAIVERS AND CODE OF CONDUCT
Please print the following waivers and upload with your signatures: https://app.box.com/s/vfiok0gz4kd9r4ci9441yazyvw6jdzms https://app.box.com/s/1e9u2d2j5y1rmmfjuvoums0tovvx8jhl
Upload the YMCA Waiver here:
Browse Files
Cancel
of
Upload the RYLA Code of Conduct here:
Browse Files
Cancel
of
Submit
Should be Empty: