2020 RYLA Registration Form

This online form must be completed in full and signed by both the student and a parent or legal guardian in multiple places. Incomplete forms will delay (or preclude) registration for RYLA.

This online Registration form must be completed and submitted NO LATER THAN APRIL 15, 2020.

NOTE: At any time during completion of this Registration form,
you can save your work and return if you need time to gather information.

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Gender *
2020 RYLA Weeks. Select one:
[1: June 14-19; 2: June 21-26; 3: July 12-17] *
T-Shirt Size *

instructions
  • Please read and sign the Student/Parent Commitment at the bottom of this page, (parents too!).
  • One or both parents (or guardian/s) must sign both signature lines on page 2 of this form.
  • Have your family physician complete the Doctor’s Certificate on page 3 or attach a current copy of your school physical.
  • Have your parents read and sign the Parental Authorization and Release on Page 4
  • Both the student and parent/s must read Page 5, Code of Conduct and sign where indicated.
STUDENT/PARENT COMMITMENT
  • I agree to arrive at RYLA by the designated start time (12 Noon on Sunday) and remain at RYLA until AFTER closing ceremonies on the last day, Friday (1 PM). The only EXCEPTIONS to this rule will be medical emergencies. Otherwise, NO EXCEPTIONS!
  • I agree to FOLLOW all RYLA Rules as specified at the www.camp-ryla.org website and in this application, and to travel to and from RYLA by transportation arranged by my sponsoring Rotary Club (or make special arrangements to travel to and from RYLA by other means, with my parent’s permission and the consent of the RYLA Director).
  • I certify that I am a JUNIOR in high school now and will be a SENIOR this coming fall.
  • I agree to, and understand that, as a participant, I may be photographed during RYLA, and that Rotary and its representatives may use RYLA photographs or images in publications or communications primarily to educate and promote awareness of RYLA and Rotary’s commitment to youth.
Student Signature *
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Parent/Guardian Signature *
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This form must be completed and submitted NO LATER THAN APRIL 15, 2020

Medical Statement

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Allergies: [List all known and attach separate list if necessary]
 Known AllergiesDescribe reaction & Management
Allergy 1
Allergy 2
Allergy 3

Medications Being Taken

Please list ALL medications (including
over-the-counter or nonprescription
drugs) 
taken routinely. Bring enough
medication to last the entire time at
RYLA. Keep it in the original packaging
or bottle that identifies the prescribing
physician (if a prescription drug), the
name of the medication, the dosage,
and the frequency of administration.





If no medications, check here
Medications: [attach separate list if necessary]
 MedicationDosage
Medication 1
Medication 2
Medication 3
Permission to Provide Necessary Treatment or Emergency Care:
I hereby give permission to the medical personnel selected by the RYLA Director to order x-rays, routine tests, treatment, to release any records necessary for insurance purposes, and to provide or arrange necessary related transportation for me or my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the RYLA Director to secure and administer treatment, including hospitalization, for the person named above.
Signature of Parent or Guardian
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Signature of Parent or Guardian *
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Insurance Information
Family medical and/or
hospital insurance? *

NOTE: In order to facilitate treatment in an emergency,
please upload a photocopy of your health insurance card (front and back).
PDF format is preferred.

This online form must be completed and submitted
NO LATER THAN APRIL 15, 2020

Doctor's Certificate

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This is to certify that this student has been recently examined by me and they are in 
Good health
Student will be able to participate in RYLA Activities and sports.
Student's condition requires
medications that are necessary
at RYLA.
Doctor's Signature
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NOTE: We will accept a current (this school year) copy of your school physical in lieu of this doctor’scertificate. Please attach a copy and answer the following question:

Are you aware of any condition expressed
by a health care provider that would contradict
the information contained in the school physical
certificate?
Will you be submitting
your schoold physical
in lieu of your doctor's
certificate?

This online form must be completed and submitted NO LATER THAN APRIL 15, 2020.

Parental Authorization and Release

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PARENTAL AUTHORIZATION:

I do voluntarily consent to my son’s or daughter’s good health and to participation in all RYLA activities, including the ropes course, to be held at Grizzly Creek Ranch, Portola, California on one of the afore mentioned dates. I assume responsibility for any medical or treatments fees or costs incurred directly or indirectly because of said minor’s participation.

I also authorize the representative(s) of Rotary Districts 5180/5190 to arrange for professional care and treatment in case of a medical emergency. I hereby give my permission to the physician selected by the Rotary representative to hospitalize, secure professional treatment for and/or to order injections, anesthesia, and/or surgery for the minor named above.

RELEASE, ASSUMPTIONS OF RISK AND AGREEMENT TO HOLD HARMLESS

In consideration of the sponsoring Rotary Club, Rotary International District 5180 and/or 5190, I permit my child to participate in RYLA and to engage in all related activities. I hereby assume the risk associated with participation and agree to hold the RYLA 5180/5190, Inc., the sponsoring Rotary Club, Rotary International Districts 5180 and 5190, their committees, employees, agents, representatives and volunteers harmless from any and all liabilities, actions, causes of action, claims or demand of any kind and nature whatsoever that may arise by or in connection with my child’sparticipation in any activities related to RYLA, including the full day Ropes Challenge Course. The terms here shall serve as a release and the assumption of the risk for my child, his or her heirs, estate, executor, administrator, and assignees as well as members of my family.

I grant Rotary Districts 5180 and 5190 and the sponsoring Rotary Club permission to use the image of the above-named minor for educational and promotional purposes. In addition, Rotary Districts 5180 and 5190 may contact the above-named minor regarding other Rotary programs, including, but not limited to, Interact, Rotaract, speech contest, musical performance contest and scholarship opportunities.

Parent or Guardian #1 *
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Parent or Guardian #2 *
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This online form must be completed and submitted NO LATER THAN APRIL 15, 2020.

RYLA Rules and Code of Conduct

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  • All prescription and over-the-counter drugs must be in the possession of the RYLA Nurse and will be dispensed as needed.

  • Students are not allowed to bring food of any kind into the cabins. It attracts wildlife.

  • Issued T-shirt is to be worn at all times except for free time and evening activities.

  • No alcohol or illegal drugs or recreational drugs are allowed on the premises.

  • Smoking is not permitted at any time on the premises.

  • Students are not permitted off-site at any time without an adult escort.

  • Cell phones, cameras, video recording devices and other internet connective

    devices are forbidden.

  • No boy/girl co-mingling in cabins at any time. This means female students are allowed only in female designated cabins and males are only allowed in male designated cabins.

I understand that if my SON/DAUGHTER is foundto be in possession of liquor, drugs, tobacco products or unidentified medications, or otherwise violates the RYLA Rules, he/she will be sent home at my expense. as a parent and/or guardian, I remain legally responsible for any actions taken by the above-named student.
 
RYLA Non-Discrimination Policy
 

RYLA is committed to providing all students with a safe and supportive environment free from discrimination on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, or sexual orientation in all of its activities and operations.

RYLA Youth Protection Policy

Rotary International's Statement Conduct for Working with Youth

Rotary International strives to create and maintain a safe environment for all youth who participate in Rotary activities. To the best of their ability, Rotarians, Rotarians' spouses and partners, and other volunteers must safeguard the children and young people they come into contact with and protect them from physical, sexual, and emotional abuse.

A complete copy of the 5180/5190 Youth Protection Policy is available upon request.

 

Student signature *
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Parent/Guardin signature *
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Before you SUBMIT this application, please review and print a copy for yourself.
[To Print: Contrl+P or Right-Click, select Print] 
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