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District 6760
2010 Rotary Youth Leadership Awards (RYLA) Application
Student Information (required)
Name: ______________________________________ _______________________________ ________
(Last) (First) (M.I.)
Preferred Name/Nickname: ___________________________ Date of Birth: _______________________
Home Address: ____________________________________________________________________________
City: ___________________________________ State: _________ Zip Code: _______________
Home Phone: ______________________________ Cell Phone: _______________________________
E-mail: ___________________________________ Gender: __ M __ F T-Shirt Size: ___________
School: ___________________________________ Fall 2010 Grade: ___ 10th ___ 11th ___ Other
(please list year)
Parent/Guardian Information (required)
Parent/Guardian Name: __________________________________ ________________________________
(Last) (First)
Emergency Contact Number(s): ____________________ ____________________ _____________________
E-mail: _______________________________________ Approx. # of Guests at Tues. 6/20 Graduation: ___
Sponsoring Rotary Club Information (required)
Rotary Club Name: _________________________________________________________________________
Rotary Contact Person: ___________________________________ ________________________________
(Last) (First)
Phone Number(s): ___________________ ___________________ Email: __________________________
Page 1 of 9 APPLICATION DEADLINE: April 30, 2010 Revised: Jan. ‘10
Student Involvement
School/Community Involvement: Please list any community, church, or school activities in which you have
participated. Please list any position(s) of responsibility or recognition you have received for your
involvement.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Work/Volunteer: Please list any paid or volunteer work experience(s) and briefly describe it/them.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Do you currently have a job? Yes No If so, how many hours per week do you work? _________
If you participate in sports, please list them: _____________________________________________________
__________________________________________________________________________________________
Please explain why you want to participate in the RYLA program? (Attach additional sheets, if necessary.)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Page 2 of 9 APPLICATION DEADLINE: April 30, 2010 Revised: Jan. ‘10
Student Medical Information (required)
Do you have any physical or medical conditions or restrictions? If so, please explain: ___________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Any known allergies: ________________________________________________________________________
Date of Last Tetanus Shot: _________________
Physician’s Name: ________________________ Physician’s Phone: _______________________________
Insurance Company: ______________________ Insurance Co. Phone: _____________________________
Ins. Subscriber’s Name: ____________________ Insurance ID Number: _____________________________
May acetaminophen (such as Tylenol) be given to the student? Yes No
May stomach remedy medicines (such as Pepto Bismol) be given to the student? Yes No
Any additional information or special instructions: _______________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
PLEASE ATTACH A COPY OF THE
STUDENT’S HEALTH INSURANCE CARD
TO THIS APPLICATION
Photo Release
At various times throughout the RYLA Program, Rotary District 6760 representatives will be taking digital
images, photographs, and/or videotapes of the program for public educational, promotional and/or
informational purposes. When/if you or your child’s likeness or image is used in a publication, there will be no
identifying information provided (i.e. child’s name, personal information) and no compensation.
I give permission to representatives of the RYLA Program and Rotary District 6760 to take and publish, in
print, electronic, or video format, the likeness or image of my child and/or myself.
Page 3 of 9 APPLICATION DEADLINE: April 30, 2010 Revised: Jan. ‘10
Student Signature
The RYLA program is an intensive leadership experience; and thus, partial attendance is not allowed. All
applicants must be certain that full attendance will occur, if selected. As the student applicant, by my
signature, I hereby commit to attend the entire 2010 District 6760 RYLA Program at Austin Peay State
University from June 17 to 20, 2010, if selected for attendance.
Student Signature: ___________________________________________ Date: _______________________
Parent/Guardian Signature
As parent/guardian, by my signature, I realize that participation in the RYLA Program is voluntary; and thus,
will not hold the sponsoring Rotary Club, Rotary Youth Leadership Awards, Rotary District 6760, Rotary
International, or the ALOC Group liable for possible injury or loss that may occur during the program. I am
also aware of and agree to comply with the policy of attendance, as stated above.
Parent Signature: ____________________________________________ Date: _______________________
Sponsoring Rotary Club Signature
As the representative of my District 6760 Rotary Club, by my signature, I confirm my Rotary Club’s sponsorship
of the above named student applicant. I understand that it is my responsibility to assure that payment for my
club’s sponsorship is attached to this application, when submitted.
Club Representative Signature: _________________________________ Date: _______________________
Completed applications can be mailed with payment by April 30th to:
District 6760 RYLA Committee
c/o Ryan Forsythe
346 Andrew Drive
Clarksville, TN 37042
Email: forsyther@apsu.edu
Phone: 978-314-6037
Checks Payable To: “District 6760 – RYLA”
Page 4 of 9 APPLICATION DEADLINE: April 30, 2010 Revised: Jan. ‘10
Application Checklist
To apply for the 2010 Rotary Youth Leadership Awards (RYLA), submit all of the following:
This completed application (all 9 pages)
Copy of student’s (or parent’s) Health Insurance Card
Fee payment (paid by the Sponsoring Rotary Club; Payable to ‘District 6760 – RYLA’)
o $400 for each participant
Completed applications can be mailed by April 30th to:
District 6760 RYLA Committee
c/o Ryan Forsythe
346 Andrew Drive
Clarksville, TN 37042
Application Process/Timeline
Feb. 15th Application materials made available to District 6760 Rotary Clubs
Mar. 1st Rotary Club provides application materials to prospective RYLA applicants
Apr. 1st RYLA applicants complete application materials and return to Rotary Club
Apr. 30th Rotary Club forwards applications (with $400 payment) to the RYLA committee
May 15th Official 2010 District 6760 RYLA Acceptance Letters sent to selected RYLA participants
Jun. 17th RYLA program begins with check-in at 10:00 am
Jun. 20th RYLA program ends with graduation, which will be held from 2:30 pm to 3:30 pm
Schedule
Thurs. Jun. 17th 10:00 am Check-in
12:00 noon – 10:30 pm Lunch and then RYLA activities all day
Fri. Jun. 18th 7:30 am – 11:00 pm RYLA activities all day
Sat. Jun. 19th 7:30 am – 12:00 midnight RYLA activities all day
Sun. Jun. 20th 7:30 am – 2:30 pm RYLA activities
2:30 pm – 3:30 pm Graduation (family and friends invited to attend at
APSU Morgan University Center)
3:30 pm Departure
Page 5 of 9 APPLICATION DEADLINE: April 30, 2010 Revised: Jan. ‘10
Things to bring
A Great Attitude!
Bed linens (extra long twin), Mattress Pad, Pillow and Pillow Case
Cover / Comforter (the building is air conditioned)
Bath Towel, Hand towel
Toiletries, etc.
Casual, Comfortable Clothes for 3 ½ days
Tennis Shoes / Sneakers
Swimwear and sunscreen. There may be pool or other outdoor activities, depending on weather.
“Award Ceremony Clothes” – Pictures will be taken of your award being presented to you. No, it
doesn’t need to be a coat and tie, just something a little nicer.
Photo ID
Money – All your meals and needs are paid for by your sponsoring Rotary Club and District 6760. You
only need to bring a small amount of money for vending machines or other incidental expenses, if you
so desire.
Cell Phone – You may bring a cell phone with you. However, they must be left in your residence hall
room, during all days’ events.
Electronic Devices – You may bring personal music devices like CD players, iPods, etc., but these may
only be used during your free periods. You will be responsible for their security, if you choose to bring
them.
Things NOT to bring
Anything that may be taken for a weapon (pocket knife, etc.)
Any potentially dangerous materials (fireworks, an elephant, etc.)
Distractions. The RYLA program is an intensive leadership experience; and thus, students’ full
participation and active involvement is necessary.
Cancelations
Cancelations on or after April 30th will result in no refund of any payment made. Rotary Clubs may choose a
replacement, when possible, as determined by the RYLA committee. If it is possible for the Rotary Club to
choose a replacement in a timely manner, all necessary paperwork must be submitted for the replacement
student, by June 1st. If it is NOT possible for the Rotary Club to choose a replacement, as determined by the
RYLA committee, the RYLA committee may choose a replacement (possibly from another club) without a
refund of the original club’s fee payment.
More info
www.ryla6760.org
Page 6 of 9 APPLICATION DEADLINE: April 30, 2010 Revised: Jan. ‘10
ALOC Group LLC
7051 Hwy 70S #309 • Nashville, TN 37221 • 615-269-6004 • FAX 615-523-1299
Student Program Applicant Information
Your school/org. name:_____________________________________
Your program dates:_______________________________________
To Parents: Thank you for completing this form on behalf of your son or daughter. ALOC Group LLC is a team building
and leadership development training company. Our programs use a wide variety of games, team-building activities, and
low challenge course activities. (Since this is a general description only, please refer to accompanying information or
school personnel to find out more about the specific activities planned for your son or daughter's program.) Although some
of these activities can be physically demanding, they are designed to be within the capability of any student who is in
reasonably good health. Safety is a very high priority for all of our programs. Please help us by providing the information
requested below. If your child has any current or past medical conditions that could affect their participation, please let us
know. If you have additional questions about this program please contact the appropriate school personnel or a
representative of ALOC Group LLC. --Thank You
General Information
Student's Name:__________________________Date of Birth:____________________
Home
Address:______________________________________________________________
_____________________________________________________________________
Sex: M F
Parent(s)/Guardian(s):___________________________________________________
Home Phone:__________________ Business Phone:_________________________
If you are not available in an emergency situation, please indicate an additional person
to be notified:
Name:_____________________________________Phone:_____________________
Relationship to student:__________________________________________________
Address:______________________________________________________________
Insurance Information
Page 7 of 9 APPLICATION DEADLINE: April 30, 2010 Revised: Jan. ‘10
Is this student covered by family medical/hospital insurance?..................................Yes
No
If so, indicate carrier of plan name __________________Group #:_________________
Carrier address:________________________________________________________
Name of insured:_______________________________________________________
Relationship to participant:_______________________________________________
Medical Questions
Does your child have any current or past medical conditions that could affect their
ability to participate in ALOC Group activities?..............................................Yes No
If yes, identify and explain:
_____________________________________________________________________
_____________________________________________________________________
Release of Liability — Acknowledgment of Risk
I understand that this ALOC Group LLC program will be conducted outdoors and that it is designed to be challenging, as
well as educational. I recognize and acknowledge that although the program has been carefully designed and will be
operated by well-trained staff, the risk of injury or disability cannot be totally eliminated. In the event of illness or injury,
consent is hereby given to provide emergency medical care or hospitalization. I affirm that the information provided is
accurate and complete and I agree to hold ALOC Group LLC harmless if full disclosure of a pre-existing medical condition
has not been provided. I release ALOC Group LLC, its staff members and Partners from all liability not directly related to
the actions of ALOC Group LLC staff members.
Media Release
I grant to ALOC Group LLC the right to use, reproduce, assign and/or distribute photographs, films, videotapes, and
sound recordings of me for use in materials they may create.
Signature:_____________________________________________________________
parent or guardian date
Although ALOC Group LLC is not subject to HIPAA (Health Insurance Portability and
Accountability Act) privacy rules (in regard to workshop participants), we do keep all
medical information and health forms confidential.
Page 8 of 9 APPLICATION DEADLINE: April 30, 2010 Revised: Jan. ‘10
Austin Peay State University Summer Camp
Parental Permission / Medical Authorization Form
Child’s Name: __________________________________________ Date of Birth: _______________________ Age:_______
Parent’s Name:__________________________________________
Address:____________________________________ __________________________________ Phone:____________________
Street City, State, Zip
In case of an emergency, illness, or accident to the child, the APSU Staff is authorized to contact the following:
st
1 Contact Name:____________________ Relationship: _____________ Home #__________________ Work #________________
nd
2 Contact Name:_____________________ Relationship:_____________ Home #__________________ Work #________________
HEALTH INFORMATION
List any health conditions that may need special consideration or attention (bee stings, allergies, epilepsy, diabetes, asthma, etc.)
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Does your child take any medications? YES_______ NO________ If yes, please indicate or list: ____________________
Allergies to any medications or anesthesia? YES_______ NO________ If yes, please indicate or list: ____________________
Date of last tetanus shot:____________________________ Date of last physical exam:___________________________________
Are there any sport activities that your child cannot participate in?___________________________________________________
Personal Physician’s Name:_______________________Phone:________________ Do you have insurance? Yes____ No____
If yes, please complete the following:
Insurance Company:___________________________Policy #______________
Subscriber’s Name:________________Relationship:_____________
In the event of a medical emergency requiring more than basic first aid, I understand that all feasible attempts to contact me will be
made. I also understand that in order to obtain the quickest medical treatment for my child Austin Peay State University will activate
EMS and, if necessary, transport my child to the nearest emergency facility. Rather than follow this procedure I request that the
following alternative plan be adopted for my child:
PARTICIPATION AGREEMENT
I understand and agree that there is a risk of serious injury to me while utilizing University Recreation facilities, equipment, and programs and
recognize every activity has a certain degree of risk, some more than others. By participating, I knowingly and voluntarily assume any and all risk of
injuries, regardless of severity, which from time to time may occur as a result of my participation in athletic and other activities through APSU University
Recreation.
I hereby certify I have adequate health insurance to cover any injury or damages that I may suffer while participating, or alternatively, agree to
bear all costs associated with any such injury or damages myself.
Parent or Guardian Signature:__________________________________________________ Date: __________________________
Page 9 of 9 APPLICATION DEADLINE: April 30, 2010 Revised: Jan. ‘10
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