MyEventRunner - Event Public Fill

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User Name:

Password:

Your Information

Select Your Sponsoring Club:

First Name:

Last Name:

Badge Name:

Email:

Preferred Phone:

Address 1:

City:

Zip/Postal Code:

State/Province:

Name of High School:

Type of High School:

Submitting RYLA Student Registration Form:

Gender:

Are you currently a member of Interact?:

T-shirt Size:

Date of Birth - (Date MM/DD/YYYY):

Parent/Guardian #1 - First & Last Name:

Parent/Guardian #1 - Home Phone (XXX) XXX-XXXX:

Parent/Guardian #1 - Cell Phone (XXX) XXX-XXXX:

Parent/Guardian #1 - Work Phone (XXX) XXX-XXXX:

Parent/Guardian #1 - Email (Required for Medical Release purposes):

Parent/Guardian #2 - First & Last Name:

Parent/Guardian #2 - Relation (mother, father, grandparent, etc.):

Parent/Guardian #2 - Home Phone (XXX) XXX-XXXX:

Parent/Guardian #2 - Cell Phone (XXX) XXX-XXXX:

Parent/Guardian #2 - Work Phone (XXX) XXX-XXXX:

List and explain any health conditions or physical limitations of participant (e.g. asthma, heart, convulsions, diabetes, recent injuries limiting mobility, crutches, etc.:

List allergies, if any:

Participant needs medications administered while attending RYLA (prescription and over the counter). IMPORTANT: ALL MEDICATIONS MUST BE IN THE ORIGINAL CONTAINER. MEDICATIONS WILL BE ADMINISTERED BY MEDICAL STAFF AND MUST BE GIVEN TO THE STAFF MEMBER AT REGISTRATION WITH ANY SPECIAL DISPENSING GUIDELINES*:

First Medication Name | Dosage | Frequency (e.g. with lunch, at bedtime, Emergency or as needed:

Second Medication Name | Dosage | Frequency (e.g. with lunch, at bedtime, Emergency or as needed:

Third Medication Name | Dosage | Frequency (e.g. with lunch, at bedtime, Emergency or as needed:

Primary/General Practitioner - Name:

Primary/General Practitioner - Phone Number:

Primary/General Practitioner - Address:

Allergy Concerns:

Explain any Allergy Concerns:

Explain any additional medical concerns/conditions:

Limitations- Are there any pre-existing medical conditions or other reasons why this camper could not or should not participate in physical activities? (eg. hiking, running, climbing, rafting, etc.):

Explain any pre-existing medical conditions or other reasons why this staff member could not or should not participate in physical activities:

Emergency Contact - First & Last Name:

Emergency Contact - (XXX) XXX-XXXX:

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 5870 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. Required

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