2025 Rotary Camp Pop-Up

Through the Pop-Ups you will learn about yourself and others and about motivation and teamwork. Learn more about camp specifics by visiting sckans.edu/rotarycamp or by emailing leaders@sckans.edu or calling (620) 229-6367 with questions.

Rotary Camp Pop-Up 2025 is scheduled for:

Saturday, February 22 - Cosmosphere, Hutchinson, KS

Time: 9am-3pm
Theme: “Celestial Leaders”
Meal: Light Lunch @12:00

Deadline for sign-up is Friday, February 7, 2024. There will be no refunds, unless there is an exceptional reason.

If seeking scholarship funding from your local Rotary Club, you are responsible for contacting your club and requesting payment. Contact leaders@sckans.edu if you are uncertain about how to contact your local club.

The SC Leadership Rotary Camp is implemented through a partnership with RYLA. Rotary Youth Leadership Awards (RYLA) and SC Leadership provide an intensive training program that brings together high school aged youth to futher develop character and leadership skills and learn about the ideals of Rotary.

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

Phone*

Area CodePhone Number

Shirt Size

High School*

Class of *

Please describe any special food allergies or dietary needs:

Why would you like to attend the camp?*

Gender*

MaleFemaleNon-Binary/Transgender

Emergency Contact Name*

First NameLast Name

Emergency Contact E-mail*

Emergency Contact Cell Phone*

Area CodePhone Number

Emergency Contact Work Phone*

Area CodePhone Number

Medical Consent

I understand and agree that Releasees may not have medical personnel available at the location of the Program. In the event of any medical emergency, select your consent below:

In the event of any medical emergency...*

I DO authorize and consent to any x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care that Southwestern College personnel deem necessary for my safety and protection. I understand and agree that Releasees assume no responsibility for any injury, illness, or damage which might arise out of or in connection with such authorized emergency medical treatment. I further understand that in the event that I experience any condition requiring emergency medical treatment, Southwestern College may direct that I be transported to the hospital for such care.I DO NOT authorize and consent to any x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care that Southwestern College personnel deem necessary for my safety and protection. I understand and agree that Releasees assume no responsibility for any injury, illness, or damage which might arise out of or in connection with such authorized emergency medical treatment. I further understand that in the event that I experience any condition requiring emergency medical treatment, Southwestern College may direct that I be transported to the hospital for such care.

Payment

The Pop-Up camp costs $150. Scholarships, which may cover the full cost of the camp, are available through local Rotary clubs. Local clubs must be notified by the applicant and scholarship requests approved prior to Feb. 7, 2025. All payments are due by Feb. 7, 2025.

Please make checks payable to: Rotary Youth Leadership Camp

Send to:

Community National Bank & Trust
Attn: Rotarian, Dean Kennedy
P.O. Box 637
Winfield, KS 67156

Method of payment:*

Full scholarship payment to be made by Rotary ClubPartial scholarship payment by Rotary Club and partial payment made by individualFull payment to be made by individualOther payment method

Sponsoring Rotary Club Number

(*You are responsible for contacting your club to request payment prior to ???)

Sponsoring Rotary Club has approved your sponsorship?

YesNo

Please indicate the dollar amount to be paid by Rotary Club

Please indicate the dollar amount you will be paying.

Other payment method details

It is vital that the SC Rotary Camp keeps updated records of events and an active website which may contain student's photos. Names of students will never be identified.*

As a condition of my participation, I DO grant Southwestern College the right to use, for promotional purposes only, any photographs of me taken by Southwestern College, its employees or agents, during my participation in the Program. I further understand and agree that Southwestern College may use (for marketing purposes) any statements or quotes attributed to me in my evaluation of the Program.As a condition of my participation, I DO NOT grant Southwestern College the right to use, for promotional purposes only, any photographs of me taken by Southwestern College, its employees or agents, during my participation in the Program. I further understand and agree that Southwestern College may use (for marketing purposes) any statements or quotes attributed to me in my evaluation of the Program.

Participant Signature

I hereby acknowledge that I have read, understand, and will abide by each of the terms and conditions of this Agreement. I understand that I may seek legal counsel of my own choosing to fully explain any terms of this Agreement to me before I sign it.

Participant Signature*

Signature of Parent/Guardian for Participants Who Are Minors

I certify that I have custody of Participant or am the legal guardian of Participant by court order. I HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND AND AGREE TO ITS TERMS. I AM AWARE THAT THIS AGREEMENT INCLUDES A RELEASE AND WAIVER OF LIABILITY, AN ASSUMPTION OF RISK, AND AN AGREEMENT TO INDEMNIFY RELEASEES.

Signature of Parent/Guardian*

Southwestern College is committed to a policy of nondiscrimination on the basis of race, color, gender, age, religion, national origin, handicap, or other nonmerit reasons, in admissions, educational programs or activities, and employment, all as required by applicable laws and regulations. Responsibility for coordination of compliance efforts and receipt of inquiries, including those concerning Title IX of the Education Amendments of 1972 and Section 504 of the Rehabilitation Act of 1973, has been delegated to the vice president for business affairs, Christy Administration Building, Southwestern College, 100 College Street, Winfield, KS 67156-2499, (620) 229-6000. Southwestern College complies with the Crime Awareness and Campus Security Act of 1990. The yearly report is available from the dean of students upon request. Race and ethnic origin information is voluntary and will not be used in a discriminatory manner.

2025 Rotary Camp Pop-Up

Attendee Information

Emergency Contact Information

Waivers & Policies

Photo & Video Release