2024 RYLA Registration Form

Description Text

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 MAY 15, 2024.

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

Save & Return

Save your progress and complete this form later. (optional)

Date

District *

Rotary Club *

First Name *

Last Name *

Street Address *

City *

State *

Zip Code *

Cell Phone *

Email Address *

Birthdate *

Gender--for cabin placement *

M

F

High School *

Parent/Guardian *

Parent Phone *

Parent Email *

Session *

June 16-21

June 23-28

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 parents read and sign the Parental Authorization and Release on Page 3
Both the student and parent/s must read Page 4, Code of Conduct and sign where indicated.

STUDENT/PARENT COMMITMENT

I agree to arrive at RYLA by the designated start time (11 AM 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 preferably travel to and from RYLA either with one or both parents or by transportation arranged by my sponsoring Rotary Club which might involve transportation with a designated Rotarian driver or via bus from the Sacramento region.
I certify that I am a JUNIOR or SENIOR in high school at this moment. Also, if over 18 years of age at start of requested session, I guarantee that I have not been convicted of a violent crime.
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 *

clear

Parent/Guardian Signature *

clear

This form must be completed and submitted NO LATER THAN MAY 15, 2024

Medical Statement

Save & Return

Save your progress and complete this form later. (optional)

Date *

Student Name *

Allergies: [List all known and attach separate list if necessary]

	Known Allergies	Describe reaction & Management
Allergy 1	Known Allergies	Describe reaction & Management
Allergy 2	Known Allergies	Describe reaction & Management
Allergy 3	Known Allergies	Describe reaction & Management

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

NO medications on a routine basis.

Medications: [attach separate list if necessary]

	Medication	Dosage
Medication 1	Medication	Dosage
Medication 2	Medication	Dosage
Medication 3	Medication	Dosage

Please list any dietary restrictions

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

clear

Signature of Parent or Guardian *

clear

Insurance Information

Family medical and/or
hospital insurance? *

Yes

No

If covered, Career/Plan Name *

Group #

Carrier Address

Name of insured

Relationship to student *

Upload copy of insurance card - front and back. *

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 MAY 15, 2024

Save & Return

Save your progress and complete this form later. (optional)

This online form must be completed and submitted NO LATER THAN MAY 15, 2024.

Parental Authorization and Release

Save & Return

Save your progress and complete this form later. (optional)

Date *

Student Name *

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 am aware that all possible precautions are in place to protect my son/daughter from exposure to the COVID-19 virus and that detailed plans exist to deal with such exposure(s) should they occur. (The Sierra Nevada Journeys exhaustive COVID-19 protocols are available upon request).

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 *

clear

Printed Name of Parent or Guardian #1 *

Parent or Guardian #2 *

clear

Printed Name of Parent or Guardian #2 *

This online form must be completed and submitted NO LATER THAN MAY 15, 2024.

RYLA Rules and Code of Conduct

Save & Return

Save your progress and complete this form later. (optional)

Date *

Student Name *

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 RYLA T-shirt is to be worn at all times except for free time and evening activities. Provocative articles of clothing, apparel or accessories with any messaging of any kind (social, political, religious, etc.) are forbidden. Our program is designed for participants to develop authentic connections free of any preconceived perceptions that may be inferred from such items.
No alcohol or illegal drugs (nor vape pens of any kind) 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 such as Apple watches 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.

Student signature *

clear

Parent/Guardin signature *

clear

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

S	M
L	XL
XXL