2018 Application Form

Rotary Youth Program of ENrichment

2018 APPLICATION FORM

Please enter details carefully. Most communication will be via email, so please enter an address that you use frequently.
Full Name / Preferred Name for Badge
Date of Birth / Gender
Home Address / Postcode
Email(s) / Phones: / (Home)
(Mobile)
School / Year Level
Emergency Contact (Parent or Guardian) Name
Address / Postcode
Email(s) / Phones: / (Home)
(Mobile)
Health Issues
eg allergies
Dietary Issues
(choose from the list or enter NIL) / Gluten free, Celiac, Dairy free, Halal, Vegetarian, Vegan or -
Other (details please)
Current Medications (please specify or NIL)
More about You
Organisations in which you participate
Hobbies and Recreational Interests
Positions held in school / community
Probable career/ course /work
Your commitment
In making application, I understand that I will be required to undergo a selection process and that the decision of the selection panel is final.
I acknowledge the essential points of the Basic Code of Behaviour expected by Rotary and agree to abide by them.
I understand that to fully experience and benefit from RYPEN, the use of mobile phones, IPods and the like is restricted.
Signature of applicant / Date
Parent or Guardian Consents
Medicare number
( If you choose not to provide the applicants Medicare number please ensure that it is available in case of emergency.)
I authorise the Seminar Administrator to arrange medical treatment and/or ambulance transport for my child at my cost, if in her/his opinion such is necessary.
I give my consent for my son/daughter/ward to attend this R-YPEN Seminar under the terms outlined.
Signature of Parent / Guardian / Date
Permission for the use of images
I give permission for the Rotary District 9520 to use appropriate photo images of me/my child/ward in presentational and promotional materials, information brochures and on the District website www.rotarynews.info/d9520
Signature of Applicant / Date
Signature of Parent / Guardian / Date
OR Special Conditions
I apply the following restrictions on the reproduction of any photo of me/my child/ward.
Signature of Applicant / Date
Signature of Parent / Guardian / Date
FOR COMPLETION by the SPONSORING CLUB
Rotary Club / Club President
Club contact person / Contact’s phones:
home & mobile
Contact’s Email
Payment / Cheque No / Made out to RYPEN D9520
Forward payment to / Treasurer: Peter MacAuley / Or by preferred method: Direct Debit
BSB: 105-152 Account: 032 575 940
Info: Rotary club
Forward application
electronically to /
Or by post to / Administrator; Denise Luker
30 Flinders Avenue, Seaford 5169
Due Date / 30 March 2018
R-YPEN SUMMARY
Nunyara; Belair / 20 April – 22 April 2018
Closing dates for applications to Clubs / 24 March 2018
Closing dates for applications to District / 31 March 2018
Registration Fee / $275 paid by sponsoring Rotary Club
Seminar Registration / 3pm Friday 20 April 2018
Seminar Close / 3pm Sunday 22 April 2018
QUERIES
Stephany Martin: District Chair
Denise Luker: Administrator /
0439 572 495
0449 040 254