ROTARY YOUTH LEADERSHIP AWARD (RYLA) by 26YpjU

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									               ROTARY YOUTH LEADERSHIP AWARD (RYLA)
             HIGH SCHOOL CANDIDATE INFORMATION FORM (4 Pages)

        HIGH SCHOOL RYLA Program – June 27 - July 1, 2010 at the RIT Campus.

SECTION I CANDIDATE INFORMATION Please Print ALL information
Name________________________________________________________Male___Female___
           (Last)                   (First)       (MI)
Address (St)____________________________(City)_____________(State)____ Zip)________
Graduation Year__________________________ Email Address_________________________
High School Attending_____________________ Awards & Recognition’s _________________
______________________________________________________________________________
Special Interests/Talents_________________________________________________________
Parent/Guardian Name___________________________________________________________
Address_______________________________________________________________________
Phone (Day)__________________(Night)____________________(Cell)___________________

SECTION II…HEALTH INFORMATION Please Print ALL information
Health Insurance Company ____________________________Policy #_____________________
Limiting Physical Disabilities or Conditions__________________________________________
Allergies or other concerns________________________________________________________
Medication (s) presently taking____________________________________________________
REQUIREMENT: 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, in writing, to update any and all information including medical
issues prior to arrival.
Emergency Contact Person________________________Relationship_________________
        Phone (Day)__________________(Night)_______________(Cell)__________________

SECTION III SIGNATURE
Candidate Signature_________________________________Date________________
Applicant has no physical condition that could prohibit total participation.
Parent’s/Guardian’s Signature____________________________Date______________
Parent’s Signature required for students under 18 years old.
                   RETURN FORM TO SPONSORING ROTARY CLUB
******************************************************************************
ROTARY CLUB ENDORSEMENT Please Print ALL information
       The Rotary Club of __________________________will sponsor the above candidate for
the High School RYLA program in the spring of 2010.

Print Name___________________________ Signature________________________________
             Club President or Club RYLA Chairperson (email) ______________________

Questions? Robin Schmidt, Dist. 7120 RYLA Chair….      Robin0932@aol.com
                                                       585-370-2389 (cell)

Rotary Club RYLA Chair Please Mail Completed Form along with Check for $465 payable to
Rotary District 7120 to Robin Schmidt, 2169 Ridge Road, Ontario, NY 14519



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Please write about your definition of LEADERSHIP, how your current and/or future leadership
roles fit that description and what they mean to you.




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




Why are you interested in attending RYLA?




What leadership topics would you be interested in learning more about?




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ADDITIONAL FORM REQUIRED BY RIT FOR HIGH SCHOOL RYLA

                                    RELEASE OF LIABILITY

         The RYLA Program involves a variety of activities that often include games, group
initiative problems, low and high ropes course element, other physical adventure 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’s 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 complete this form
and candidate information form. Certain health/medical information must be made known to the
leaders conducting your course so they are prepared 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

I ______________________________have been chosen to participate in the Rotary District
         (Print Name In Full)
7120 RYLA program at Rochester Institute of Technology (RIT).
         I am aware that the activities in which I plan to participate 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 with 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 medical treatment for me.
         I am aware that I am expected to abide by all the rules of Rochester Institute of
Technology, roles of the program, as well as all state and federal laws. Failure to do so will be
justification for my dismissal from the program.

_______________________________________                ___________________
      (Participant’s Signature)                              (Date)


_______________________________________                ___________________
      (Parent/Guardian’s Signature)                          (Date)




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    LEADERSHIP RESPONSIBILITY CONDUCT GUIDE FOR HIGH SCHOOL RYLA

I UNDERSTAND THAT

   1. I have made a commitment to attend the RYLA camp and will notify the sponsoring
       Rotary Club immediately if conflicts arise.
   2. I may not arrive late, or leave the camp earlier than the camp’s program schedule.
   3. 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.
   4. 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.
   5. There are separate dormitory areas for males and for females. This is for the privacy and
       security of all concerned.
   6. Recreation activities are limited to those periods of the day and evening scheduled for
       such activities.
   7. If any person is injured or becomes ill, I will contact immediately the Camp Coordinator
       or the Camp Mom/Pop.
   8. I will report any damage or breakage immediately to the Camp Mom/Pop.
   9. 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 AT MY PARENT’S OR GUARDIAN’S EXPENSE.


Candidate’s Signature_______________________________Date_____________




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