Participant RYLA 2026 Registration Form

PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail

MEDICAL INFORMATION
Physician Name

First NameLast Name
Phone Number

Area CodePhone Number
Insurance
Policy or Group Number
Allergies (i.e bees, wasps, medication)/Food Allergies

Please list all medications (prescription and over the counter) that your student will bring to RYLA. Include as-needed and emergency medications.

Rows	Medication Name (as labeled)	Dosage	Time(s) Taken (e.g., “with lunch” or “bedtime”)
1.
2.
3.
4.
5.

Is your child allowed to take any of these medications if required or asked for?
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 under “Times Taken.”

Event staff will securely hold any medication students bring, but students are responsible for coming to staff at the appropriate times to take their medication. Staff will not administer or remind students to take it. Please ensure your child understands this responsibility before attending.

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Medical Concerns
RYLA Behavior/Participation Guidelines

Behavior: As a participant, you are expected to behave in an appropriate manner at all times. The standards for your behavior will be the same as those outlined in the School Code of Conduct required for every student enrolled in Kentucky Public Schools. In addition, since this is an overnight activity, all participants will be expected to go to bed and get up at the times designated in the agenda for the weekend. There will be absolutely no fraternizing between the boys and girls after lights out in the evening. ANY MAJOR BEHAVIOR INFRACTION WILL RESULT IN THE STUDENT BEING SENT HOME EARLY FROM RYLA. IN THE CASE OF ANY DISCIPLINARY ISSUES, PARENT/GUARDIAN WILL BE NOTIFIED AND IT’S THEIR RESPONSIBILITY TO PICK THEIR PARTICIPANTS FROM CAMP, IMMEDIATELY. Participation: All participants will be expected to participate in all activities of the RYLA event. Should a participant have a valid reason for non-participations in a particular activity, he or she will be expected to remain with their designated group and act as an observer for the event.
Electronics Policy: No participant under the age of 18 will be allowed to have access to personal electronic devices. In the event of an emergency, you will be able to contact the participant through designated event volunteers.
Parent Signature

Parental/Guardian Permission

Read below.
blanks has my permission to participate in RYLA - Rotary Youth Leadership Awards on September 24th- September 27th, at the Wendell H. Ford Training Center in Greenville, KY.

I know of no health or fitness restrictions that preclude participation. In the event of illness or injury occurring to my son or daughter while involved in this activity, I consent to X-ray examination, anesthesia, medical or surgical diagnostic procedures or treatment that is considered necessary in the best judgement of the attending physician and performed by or under the supervision of a member of the medical staff of the hospital furnishing medical services. (It is understood that in the event of a serious illness or injury, reasonable efforts to reach me will be attempted.) Initial Required. blank

In addition, since this is an overnight activity, students will be expected to go to bed and up at the times designated in the itinerary for the weekend. There will be absolutely no fraternizing between the boys and girls after lights out in the evening. This is considered a major behavior infraction, and any major behavior infraction will result in the student being sent home early from RYLA. In case of any disciplinary issues, I will be notified. It is my responsibility to pick up my son/daughter from camp, immediately. Initials Required. blank

I acknowledge that it is my responsibility (or the person designated on the application form) to pick up my child on Sunday, September 28th at the close of RYLA (approximately 3:00 pm CDT). I acknowledge that I have given a RYLA representative permission for my son/daughter to be picked up and driven to RYLA it for some reason, I am not able to drop off or pick them up.

Legal Guardian Signature Signature   Date
Relationship to Student
Phone number where I can be reached during the time of this activity.
Home
Mobile
Work
Photo/Video Release: I hereby allow Rotary District 6710 to use photographs or images of my child for appropriate promotional materials.

Parent Signature: Signature Date
Print Name:
Thank you for Registering!

The District 6710 Youth Services Committee will be in contact with you for more information about RYLA. For any questions, please contact Madison Harden or Aaron Poe at ryla6710@gmail.com
This is a fill in the blanks field. Please add appropriate blank fields and text.
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RYLA 2026 Registration

STUDENT INFORMATION:

PARENT/GUARDIAN INFORMATION:

MEDICAL INFORMATION

RYLA Behavior/Participation Guidelines

Parental/Guardian Permission

Thank you for Registering!