Rotary Youth Leadership Award (RYLA) Application

Rotary Youth Leadership Award (RYLA) Application

High School Candidate Information Form RYLA Program June 24-June 28, 2018 at the RIT Campus

Section 1 Candidate’s Information (Please TYPE all information inside the boxesand then print to sign)

(NO HANDWRITTEN applications will be accepted)

Last Name First Name Nick Name Gender

Home AddressCity State Zip Code

Cell # E-mail address High School Attending Grad. Year

Awards & Recognitions Special Interests / Talents

Parents Name

Full Address

Phone #s

Section II

Health Insurance Co. Policy #

List any limiting physical Disabilities or conditions, allergies, medication and special dietary needs

Requirements: All applicants are expected to be in good physical condition and to participate in all camp activities, including those which are somewhat strenuous. It is the parents’ responsibility to update, in writing, any and all information including medical issues prior to arrival.

Emergency Contact personRelationship

Phone #

Candidate Signature & Date

Parent / Guardian Signature (required for students under 18 years old) Date

Return all pages to the sponsoring Rotary Club

Rotary Club Endorsement: Please type in all information

The Rotary Club of will sponsor the above candidate for the High School RLYA program for the dates identified at the top of this application.

Type in Club President or RYLA Chair name Signature

E-Mail address

The local Rotary Club is to mail in the completed application form (all pages) with all signatures and with a check for $570 payable to Rotary District 7120 to:

Julie Carney

257 Linden St

Avon, NY 14414

If you have any questions please contact Julie Carney, District 7120 RYLA Chair by:

E-mail: ORPhone: (585) 519-9466 (cell)

Write an essay in which you address the following essential question:

“What does it mean to be a good leader?”

In your essay be sure to include the following:

Your definition of leadership;
Attributes of a good leader;
How you currently serve as a leader in your school and/or community;
What you hope to learn at RYLA that would help you to become a better / more effective leader.

How did you find out about RYLA and what do you think RYLA is about?

(If more space is needed for your essay, please continue below.)

Additional Form Requested by RIT for RYLA candidate

Release of Liability

The RYLA Program involves a variety of activities that often includes games, group initiatives problems, low and high ropes course element, other physical activities and living in a residence hall. Attendance at all events is required while the level of participation in an individual activity is at all times completely up to the individual choice. Yet there is a risk, which must be assumed by each participant that he or she may suffer an emotional or physical injury.

Policy for participation in this program requires that every participant completes this form and the candidate’s information form. Certain health/medical information must be made known to the leaders conducting your course so they can prepare to respond appropriately if the need arises. This information will be held in confidence. Please complete this form and return it along with the candidate information form to your sponsoring Rotary Club. This completed form is necessary to participate in the District 7120 RYLA program at RIT (Rochester Institute of Technology).

Assumption of Risk

If I, is,am chosen to participate in the Rotary

District 7120 RYLA program at RIT (Rochester Institute of Technology) I agree to the following:

I am aware that the activities in which I plan to participate in involve certain personal risks. I have noted on the “Candidate Information Form” any medical or physical conditions I have which might effect my participation in this activity. I therefore, release all right of claim for damages against Rochester Institute of Technology, Rotary District 7120 and all individuals assisting and conducting these activities for any injuries suffered by me in connection with this activity. In case of an emergency, I give the leaders of this activity, permission to authorize emergency treatment for me.

I am aware that I am expected to abide by all rules of Rochester Institute of Technology, rules of the program, as well as to abide by all state and federal laws. Failure to do so will be justification for my dismissal from the program.

Participant’s signatureDate

Parent/Guardian Signature Date

LEADERSHIP RESPONSIBILITY CONDUCT GUIDE FOR HIGH SCHOOL RYLA

I UNDERSTAND THAT

I have made a commitment to attend the RYLA camp and will notify the sponsoring Rotary Club

immediately if conflicts arise.

I may not arrive late, or leave the camp earlier than the camp’s schedule.

I shall attend all meetings, activities, and meals. Meals are to be eaten with other camp

participants and I shall be responsible for cleaning my area after the meal.

I MUST SLEEP in the dormitory room to which I am assigned. LIGHTS OUT is at the

scheduled time and means I shall be quiet thereafter.

There are separate dormitory areas for males and for females. This is for the privacy and

security of all concerned.

Recreation activities are limited to those periods of the day and evening scheduled for such

activities.

If any person is injured or becomes ill, I will contact immediately the CampCoordinator or the

Camp Mom/Pop.

I will report any damage or breakage immediately to the Camp Mom/Pop.

SMOKING IS PROHIBITED. This is to respect the health of all participants and because of the

potential fire hazard.

10.

ANY MEDICATIONS, whether prescribed or “over the counter” must be identified on the

container. Unidentified medications, alcohol, weapons or cigarettes found in the possession of

any participant will be confiscated.

11.

Foul or abusive language (including anything of a discriminatory nature) will not be tolerated nor

will physical violence or threats thereof be allowed.

12.

Any sexual or lewd misconduct by and/or between myself and other participants will be

considered unacceptable behavior.

13.

I MAY NOT leave the camp area FOR ANY reason without the permission of the Mom/Pop.

14.

Confidentiality is important. Anything you have shared or shared with your camp group should

remain in that group; however, camp leaders are mandated by law to report any suicide or abuse

issues to the proper authorities.

15.

I am to conduct myself in all sessions, activities, in the dining hall, in sports and in the dormitory

in a manner, which will bring credit to my school, my sponsoring Rotary Club, my family; and

myself and which will not cause injury to another person.

16.

I will present a program on RYLA to my sponsoring Rotary Club.

I have read the GUIDE and do hereby agree and commit to honoring them. SHOULD MY CONDUCT

BE CONSIDERED UNACCEPTABLE AT ANY TIME AT THE DISCRETION OF THE CAMP

LEADERS, OR SHOULD I TRANSGRESS ANY OF THE CODES STATED ABOVE, I UNDERSTAND

THAT I WILL BE DISMISSED FROM THE CONFERENCE AND WILL BE SENT HOME.

Participant Signature Date

Parent/Guardian signature Date