Rotary Youth Leadership Awards (RYLA)
2019 Iowa RYLA (Districts 5970 and 6000) Student Application
Local Rotary Club *
Select if you know the name of the your sponsoring club, otherwise select either a club near you or select "Not Sure".
Personal and Contact Information
First Name *
Your answer
Last Name *
Your answer
Nick Name
Enter name for your nametag if different from your first name.
Your answer
Gender *
This question is asked only for the purpose of assigning dorm rooms.
Street Address *
Your answer
City *
Your answer
State *
Required
ZIP *
Your answer
Home Phone *
Enter your home phone number with area code i.e. 123-456-7890. May be a cell phone number if it is your main household phone number.
Your answer
Cell Phone
Enter your cell phone number with area code i.e. 123-456-7890
Your answer
Email Address
Enter an email address where you can be reached now and during the summer of 2018.
Your answer
Re-enter Email Address
Your answer
Birth Date *
MM
/
DD
/
YYYY
T-Shirt Size *
Name of School *
Your answer
Current Grade *
Your answer
Grade Point Average (GPA)
Your answer
Parent / Guardian Names *
Your answer
Mother's Phone Number
Please enter a phone number if available in form 123-456-7890
Your answer
Father's Phone Number
Please enter a phone number if available in format 123-456-7890
Your answer
Parents'/Guardians' Email Addresses
If more than one email address entered, please separate them with a comma.
Your answer
Emergency Contact Name
Name of person to call if in case of emergency (if parents cannot be contacted immediately).
Your answer
Relationship to Applicant
What is the Emergency Contact's Relationship to Applicant?
Your answer
Emergency Contact Phone Number(s)
Your answer
Introduction *
Please introduce yourself to us.
Your answer
Awards
List any academic awards have you received.
Your answer
Activities
List your school and outside activities.
Your answer
Leadership
List leadership positions have you held in your school, club, church or community.
Your answer
Conferences
List any youth leadership conferences you have attended.
Your answer
Talents
What special talents do you have (i.e. music, art, athletics, writing, drama, others)?
Your answer
Goals
Please indicate a few career or personal goals.
Your answer
Medical Conditions *
Identify any medical conditions we should know about, any medications currently being taken, any severe allergies, treatment for any allergic reaction and dietary restrictions, or write “None”.
Your answer
Activity Restrictions *
Please write “None” if there are no activity restrictions
Your answer
RYLA Rules and Regulations
EXPECTED BEHAVIOR
Respect for property - public and private
Respect for privacy, needs and personality of others
Respect for Counselors, Staff and RYLA guests
Respect for schedule -- be on time

UNACCEPTABLE BEHAVIOR
Violating laws of Iowa
Use of tobacco, alcohol or illegal substances
Stealing, shoplifting, gambling, lying or profanity
Possession of weapons of any kind
Leaving the group without informing a counselor
Breaking curfew

Stay away from anyone who violates the rules and report them to a counselor.

Applicant Acknowledgement *
I agree that I will abide by the Rules and Regulations above. The decisions of the staff, Rotarians and counselors regarding rules infractions and discipline shall be final. I further agree that I will be available for the entire conference from 3:00 PM, Sunday July 14 through noon, Friday, July 19, 2019.
Required
Applicant Signature *
By typing your name below you acknowledge that you have read and understand the rules as stated above and agree to abide by them if you are chosen to attend RYLA
Your answer
Parent/Guardian Permission
By typing my name below I acknowledge and agree to each of the items below and I, as parent or guardian of the applicant, give my consent for my son/daughter to attend:
- Rotary's 2019 Iowa RYLA Conference,
- 3:00 p.m. Sunday, July 14 - noon Friday, July 19, 2019,
- At Grinnell College in Grinnell, Iowa.

I waive any claims for negligence against the Rotary Districts, Rotary Clubs and Rotarians and Counselors and hereby assume risk for any illness or injury by the applicant during the RYLA Conference.

In case of medical emergency, I understand that every effort will be made to contact me. In the event I cannot be reached, I understand that the Grinnell Regional Heath Center services will be available, and I hereby authorize conference officials to hospitalize, secure proper treatment and to order anesthesia or surgery for my child, for which I will guarantee payment. The the best of my knowledge, my son/daughter is in good health and I give my permission for him/her to participate in conference activities, except as noted in "Activity Restrictions".

I understand that in the event my son/daughter breaches any conference rules, he/she my be immediately sent home at my expense.

Parent or Guardian Signature *
By typing your name below you acknowledge that you give your permission for your son/daughter to attend the conference under the conditions outlined under "Parent/Guardian Permission".
Your answer
Additional Applicant Instructions
After you click "Submit", you are not quite done. If not already in contact with a RYLA Representative, please contact a RYLA Representative from the Rotary club through which you are applying. A list of the "Club RYLA Representatives" may be found via the link with the name, 'Club RYLA Representatives', at http://www.IowaRYLA.org/Rotary-Contacts. If you live in a community without a Rotary club, pick a nearby Rotary club or go back to the top of the form and select "Not Sure" for the question "Local Rotary Club" and we'll help you get in contact with a club. Thank you.
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