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District 5910
RYLA-Rotary Youth Leadership Awards

Student Registration & Commitment Form

Camp Dates: January 5-7, 2024

Pineywoods Baptist Encampment
Woodlake, Texas

RYLA - Rotary Youth Leadership Awards - is a weekend Camp experience designed for High School Juniors to teach you leadership skills, expose you to the the 4-Way Test of Rotary, challenge your critical thinking, and promote your positive character development while you bond with your peers.

Your sponsoring Rotary Club has provided a $200 scholarship for you to attend District 5910 RYLA Camp. There is no cost to you to participate except your time.

Before registering, please make sure you have have the sponsoring Rotary Club Name, no scheduling conflicts for the RYLA dates due to School, Athletics, Extra-Curricular activities, Family engagements, or Work Schedules.

An unique email address is required for each student registration. An email confirmation will be automatically generated to you upon completion of this registration form.

Your Information

Select your Sponsoring Rotary Club:

Re-Type Rotary Club Name To Confirm:

High School Name:

Type of School:

Gender:

First Name:

Last Name:

Nickname/Name for ID Badge:

Email:

Preferred Phone (XXX) XXX-XXXX:

Mobile Phone (XXX) XXX-XXXX:

Mailing Address:

City:

State/Province:

Zip Code:

Parent/Guardian - First & Last Name:

Parent/Guardian - Phone (XXX) XXX-XXXX:

Parent/Guardian - Email (Required for Medical Release purposes):

Emergency Contact - First & Last Name:

Emergency Contact - Phone:

T-Shirt Size:

Are you a member of Interact?:

YesNo

Dietary Restrictions? Be aware that not all food preferences can be accommodated.:

I consent to the collection, storage, and use of my information by Rotary District 5910 as described in this Privacy Policy. I understand that I may receive emails regarding this event and other relevant information, and can opt out at any time.

Group:
High School Junior
Rotary Youth Exchange Student
Alternate - High School Junior

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