Student Registration

Upon a successful registration you will receive a confirmation email. There will be a link to submit a Parent Consent Form. Although the form includes a lot of info pertaining to the live event you will still be required to submit with your Parent/Guardian signature.

This section to be completed by attending students.

If you have been selected to represent your Rotary Club at the upcoming RYLA, you may register for the event by completing this online form. Upon completion of this form you must click the SUBMIT button then wait to see the confirmation page, indicating your registration was successful. If you do not see a confirmation page, please send an email to admin@ryla5240.org to let us know.

Please note, all fields are required at this time other than Sponsor Cell Number, and Student Cell.

You must have a password to complete this registration. If you do not have a password, ask your sponsoring club. If you do not have contact info for your sponsoring club CLICK HERE to request contact info. You will receive a response within 48 hours.

Sponsoring Rotary Club

Rotary Club Of: Sponsor Contact Phone: Sponsor Contact Position:

Sponsor Contact Name: Sponsor Contact Cell: Sponsor Contact e-mail:

Student Information

First Name:
Gender:

Last Name:
Email Address:

The email address you provide here is crucial for us to be able to communicate important information about the event. Please make sure your email address is correct.

Address:
City:

State:

Zip Code:

Student Phone:
Student Cell:
Name of School:

Interact Club Member: Age: Grade:

GPA: T-shirt Size:

Special Talents:
College and Career Plans:
List any limitations that may prevent you from participating in any learning or physical activities:

Parental Contact Information

Please provide as much contact information as possible so we can contact your parent or guardian in the event of an emergency.

Parent/Guardian Name:
Parent/Guardian Home Phone:

Parent/Guardian Cell Phone:
Parent/Guardian Work Phone:

Parent/Guardian Email Address:

Health and Medical Information

Medical Conditions and Allergies:
Currently Taking the Following Medications:

If the student is covered under any health insurance policy please complete the following three boxes:

Name of Insured:
Policy Number:

Insurance Company:

Student Password
If you do not have the password, please contact your Rotary Club.

All students who attend a RYLA retreat are expected to read, understand and agree to the RYLA Behavior Code. The goal of the retreat is for everyone in attendance to enjoy a positive experience. Rotary has established and will enforce high standards in behavior and attitude. In addition it must be understood that all students must be prepared to attend the entire four day program. If, for any reason, you are unable to do so please contact your Rotary Club Sponsor now and inform them so a replacement can be arranged.

By checking this box I am confirming that I have read, understand and agree to the RYLA behavior Code and I understand that any students who violate the RYLA Behavior Code may be subject to immediate removal from the event at the expense of their parents and/or their sponsoring Rotary Club.