Rotary District 7910 Youth Leadership Conference
ATTENDEE REGISTRATION FORM

GENERAL INFORMATION

Enrollment Status:     ATTENDEE      ALTERNATE             |             FACILITATOR

Name  —  First:    Pref. Nickname:   Last: 

Street Address: City: State: Zip:

Home Phone #:

Cell Phone #:

Email:  

Screen Name:

SN Provider:

Parent's Email:

# of add'l people at closing program:
(this is not a commitment, it just gives us an idea of what to expect)

School:

Only if your school name is not listed above, please choose "Other..." for your school and enter the name of your school here:

Birthday (mm/dd/yy):

Gender: 
M
F

Grade: 10th 11th 12th

What date is currently expected to be your last day of school this year? (mm/dd/yy) 

What is the name of your sponsoring Rotary Club?

All conferees are provided with RYLA T-Shirts to wear during the program.
What size would you prefer:   

We encourage the attendees to share information about any service projects that they have been involved in coordinating and implementing recently.  As part of your presentation you are welcome to bring along display material as well.

Would you like to share a service project at RYLA that you have been involved in? Yes   No

Project Name: 

Briefly describe:

 

Please include any other information that you would like us to know about you:

MEDICAL HISTORY AND INFORMATION

This section must be completed and signed by a parent or legal guardian
CONFIDENTIAL
Emergency Contact Information
PRIMARY EMERGENCY CONTACT

Contact Name:

Relationship:

Address (w/CSZ):

Cell Phone:

Home Phone:

Comments or Notes:

SECONDARY EMERGENCY CONTACT

Contact Name:

Relationship:

Address (w/CSZ):

Cell Phone:

Home Phone:

Comments or Notes:

Family Doctor Contact Information

Doctor's Name:

Address (w/CSZ):

Phone:

Medical Insurance Information

Carrier Name:

Policy/Group Number:

Medical Information
ALLERGIES:
If Yes, to what (e.g. Bees, Drugs, Foods, etc.) and describe the type of reaction experienced to each.
MEDICATIONS:
List all medications that will be in the student's possession during the three day conference. 

If your child needs to carry on their person any type of medication, please list below

Various over-the-counter medications are often requested by students during the weekend such as Tylenol, Advil, or Benadryl.  Please indicate whether or not you approve for the RYLA Staff to administer these types of medications at the student's request.  Yes No
CHRONIC ILLNESSES:
If yes, what? (e.g. Diabetes, Epilepsy, Asthma, etc.)
PHYSICAL LIMITATIONS:
Does your child have any Physical Conditions or Disabilities which may prevent full inclusion in physical activities? If yes, what:
RECENT INJURIES:
If your child has experienced any injuries (e.g. dislocations, severe sprains, torn ligaments, separations, etc.) within the last three years please describe the injuries including the time frame, the severity and the current condition:
OTHER MEDICAL CARE:
If your child is currently under a physician's care (or has been within the past year) for any other reason, please explain:
Does your child wear contact lenses? Yes  No
Is your child's tenanus shot up to date? Yes  No
SPECIAL DIETARY NEEDS:
All main meals at RYLA are cafeteria-style and offer a wide variety of foods.  Additionally, snacks are provided twice a day.  If you have dietary requirements that you are concerned will need special attention, please use the space below to bring them to our attention:
Please use the space below if there is any other medical information which you feel is important to provide:

 

 

This page is only an entry form for the registration material.  You MUST click the "Register for RYLA!" button, below, for your registration packet to be displayed for printing.  If you close this web page without clicking "Register for RYLA!", your online registration cannot be completed and you will not have the necessary paperwork.

Once you click "Register for RYLA!", the registration paperwork will appear on your screen and should be printed, reviewed, and signed in each appropriate location.