Rotary Youth Leadership Awards
Iowa RYLA (Districts 5970 and 6000)
2019 Rotarian Application
Rotary Club *
Select your Rotary Club
First Name *
Your answer
Last Name *
Your answer
Nick Name
Name for your badge if different from your First Name
Your answer
Home Address *
Enter your street address
Your answer
City *
Your answer
State *
Zip code *
Your answer
Home Phone *
Enter your home phone number with area code in format 123-456-7890
Your answer
Cell Phone
Enter your cell phone number with area code in format 123-456-7890
Your answer
Email Address *
Enter a valid email address
Your answer
Gender *
Birth Date *
MM
/
DD
/
YYYY
Polo Shirt Size *
Polo shirts will be a ladies cut for females and men's cut for males unless you indicate otherwise by selecting "Other" and explaining in the text field. Also, note that polo sizes run slightly large.
T-Shirt Size *
T-shirts will be unisex so please indicate desired t-shirt size here.
Primary Contact
In case of emergency
Primary Contact's Name *
Your answer
Relationship *
Your answer
Primary Contact's Cell Phone Number *
Or best number to be reached anytime of day. Enter in format 123-456-7890
Your answer
Other Contact
In case primary contact cannot be reached in an emergency.
Other Contact's Name
Your answer
Other Contact's Cell Phone Number
Or best number to be reached. Enter in format 123-456-7890
Your answer
Rotary Experience *
Briefly summarize your Rotary service. If you have previously served as a Rotarian Volunteer at RYLA, please indicate year(s) and the name of your Counselor(s).
Your answer
Other Volunteer/Service Activities *
In the past five years. If none, write "none".
Your answer
Youth Service *
Identify experiences you've had working with youth, if any, not already described in previous questions. If none, write "none."
Your answer
Bio *
Please provide your biographical sketch as you would like it to appear in the manual; 200 words MAX! Also, please provide a photo for the manual. Send photo suitable for manual to registrar@iowaryla.org.
Your answer
Medical Conditions / Physical Limitations *
Please note any medical conditions or physical limitations we should be aware. Also, identify any dietary restrictions and choices so we can coordinate with Grinnell's food serve employees. If none of these apply, write "none".
Your answer
Requirements
RYLA: I understand that I must be present for the entire RYLA Conference and must be at Grinnell College from 10:00 AM, Saturday, July 13, 2019 to 3:00 PM, Friday, July 19, 2019. I also understand that I must be present, at Grinnell College, for the Rotarian/Counselor training session from 8:00 AM to 5:00 PM, on Saturday, June 15, 2019.

I waive any claims for negligence against Rotary Districts 5970 and 6000, the Rotary Clubs in those Districts and individual volunteers serving RYLA, and hereby assume the risk for any illness or injury during RYLA events.

As a Rotarian volunteer at RYLA, I understand that I must authorize a background check and I will be notified when to complete the online request. I further understand that I must comply with the Iowa RYLA Youth Protection Policy and complete the Youth Protection Training, which will be conducted during Counselor/Rotarian training.

Signature *
By typing your name in this field you agree to abide by the requirements, above.
Your answer
Application Process
1. Rotarian Volunteer completes application and clicks "Submit" by April 30.
2. Application is received by the RYLA Registrar who forwards it to the Conference Chair team.
3. Conference Chair team interviews and/or selects Rotarian Volunteers from applicants.
5. Conference Chair notifies applicants by May 15 whether or not they are selected.
6. Selected applicants complete the background authorization form online, a link to be provided.

See http://www.iowaryla.org/rotarian-application-process for further information.

Thank you for applying!
Please submit your application by April 30, 2019.
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