Rotary Youth Leadership Awards Conference

Note to Applicant: This application must be completed by you and a parent/guardian. Only complete this application if you have been formally selected to participate in the RYLA Conference by your local Rotary club. All fields are required.
Name:
Gender:	Male Female
Address:
City:
State:
ZIP:
Home Phone:
E-mail Address:
Date of Birth (mm/dd/yyyy):
Grade:
School:

Applicant Name:		Date:
By checking here, I agree to the above and understand my typed name serves as a signature.
Should he/she be selected, I give my child permission to participate in this Rotary District 6220 program. In case of medical emergency during which I cannot be reached, I hereby authorize any medical care necessary for my child. I also waive and release any and all claims for injuries, damages, or theft that may occur as a result of my child’s participation in this program.
Parent/Guardian Name:		Date:
By checking here, I agree to the above and understand my typed name serves as a signature.