Please Attach a Picture of Applicant
RYLA 2014
ROTARY YOUTH LEADERSHIP AWARD CONFERENCE
ROTARY INTERNATIONAL, DISTRICT 7720
NC 4-H Environmental Education Center, Columbia, NC
April 4-6, 2014
Name_________________________________________ _________________________
Last
First
M.I.
Name for Badge
Mailing Address
______________________________________________________
______________________________________________________
City
State
Zip
Home Telephone_____________________ Phone #2 or Cell #: ___________________
E-Mail: ___________________________________
Male _____
Female _____
Paren____________________________________________________________________________________
t or Guardian Name (Please Print): _________________________________________
Parent/Guardian contact phone #: 1)_______________________ 2)___________________
Full Name of High School ___________________________________________________
School Activities:
____________________________________________________________________________________
____________________________________________________________________________________
Organizations (not school related) in which you are active:_____________________________________
____________________________________________________________________________________
RYLA APPLICANT:
Complete and return this form to your Guidance counselor or sponsoring Rotary Club’s representative as soon
as possible. If you are selected, a delegate package will be sent to you at the above address in mid-March.
Please attach a small photo of applicant. Digital photos printed on regular paper are fine.
__________________________________________________________________________________________
CLUB RYLA CHAIR – Once applicants are selected, please return original forms with photo, and fees ON
OR BEFORE March 1, 2014 to:
2012 RYLA Conference, c/o Nancy Nixon, 5053 Netherwood Road, Rocky Mount, NC 27803
SPONSORING CLUB: ______________________________________________________________
CLUB’S RYLA Contact: ________________________________
Phone # ___________________
Email: ______________________________________________
ROTARY YOUTH LEADERSHIP AWARD CONFERENCE
ROTARY INTERNATIONAL, DISTRICT 7720 NC
4-H Environmental Education Center - Columbia, NC
April 4-6, 2014
STANDARDS OF CONDUCT
All delegates are expected to adhere to certain Standards of Conduct while attending the Conference. If a delegate is
found to be in violation of the following standards, his/her parents will be notified and the delegate may expect to return
home immediately at the parent’s expense.
1. Possession or use of illegal drugs, alcoholic beverages
2. Theft, misuse, or abuse of public or personal property,
3. Sexual misconduct,
4. Possession of weapons or firearms,
5. Unauthorized absence from the premises of the event,
6. Visitation in sleeping rooms occupied by delegates of the opposite sex.
Realizing these guidelines are not “all inclusive”, the RYLA Committee reserves the right to make adjustments to these
policies. Exercising good judgment will prevent occurrences which are not within the best interest of delegates to the
Conference. Delegates must attend the full Conference. Missing Friday and coming on Saturday or leaving a day early
is not permitted. Curfew violations, failure to participate in the activities of the weekend, unauthorized use of vehicles,
inviting non-delegates to visit and disturbing the peace are examples of disruptive activities.
PHOTOGRAPHY POSTING RELEASE
Photographs taken during the conference may be posted on Rotary District 7720 website or websites of local Rotary
clubs or in printed materials to illustrate the RYLA program and encourage future participants. Participation in the
conference means that parents and delegates agree to photos being taken and posted as noted, or distributed to Rotary
clubs individually or in a slideshow-type presentation. Slide show photos may also be distributed directly to all
participating RYLA. RYLA conference sponsors, Rotary District 7720 and its Rotary Clubs are not responsible for
photos taken and/or distributed by individual participants.
MEDICAL RELEASE
My son/daughter has my permission to participate in the Rotary Youth Leadership Award Conference to be held
April 4-6, 2014. I authorize any one of the responsible adults to secure any necessary medical care for said person,
including emergency surgery. I realize every effort will be made to contact parents should any medical treatment become
necessary. I release and discharge the sponsoring groups and adults from all liability whatever respecting any injuries
and/or damages sustained by my son/daughter during the Conference.
Attach a copy of both sides of insurance card.
Uninsured delegates, check here _______
Emergency Contact#1: _________________________________________________________________
Emergency Telephone: Day_____________________________ Evening/Cell ______________________
Emergency Contact #2: _________________________________________________________________
Emergency Telephone: Day_____________________________ Evening/Cell ______________________
As a condition of participation in the RYLA Conference, April 4-6, 2014, I agree to be bound by the terms of
the Standards of Conduct, the Photography Posting release and the Medical Release.
Delegate_____________________________________________ (Signature) Date_________________
Parent/Guardian_______________________________________ (Signature) Date_________________