Rotary Youth Leadership Awards

District 6630

Participant Application

The Rotary Youth Leadership Award is a scholarship presented by your local Rotary Club to youth who have shown desire to be better leaders. Your Rotary Club offers the students the opportunity to attend a 5-day residential leadership camp at Baldwin Wallace University, June 9-13, 2024, at no charge to the recipient.

TO BE ELIGIBLE, YOU MUST BE A JUNIOR AT THE TIME OF APPLICATION.
Please complete this application.

PERSONAL INFORMATION

Last Name: *

First Name: *

Gender Identity: *

MALE

FEMALE

NON BINARY

ADDITIONAL CATEGORY: (Please Specify) ADDITIONAL CATEGORY: (Please Specify)

Preferred Pronouns:

Email Address: (Please provide an email address that you will have access to over the summer) *

Address: *

2nd Address:

City: *

Zip: *

Cellphone: *

Is your cellphone a Smartphone? *

YES

Permanent Phone:

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

HIGH SCHOOL INFORMATION

High School: *

High School Address (#Street/City/Zip):

High School Counselor/Staff Representative:

High School Counselor/Staff Representative Email:

SPONSORING ROTARY CLUB INFORMATION

Sponsoring Rotary Club: *

Rotary Club Contact Representative Last Name: *

Rotary Club Contact Representative First Name: *

Rotary Club Contact Representative Email: *

Rotary Club Contact Representative Phone:

T-SHIRT INFORMATION

SOCIAL MEDIA INFORMATION

Facebook:

Twitter:

Instagram:

Snapchat:

ACTIVITIES INFORMATION

Please supply your activities and experiences for the sections below.

School Activities: *

Community Service:

Work Experience:

Hobbies:

If you have a resume, please upload it to this section.

ESSAY INFORMATION

ESSAY: In 200 words or less, please explain why you should be a Rotary Youth Leadership Award Recipient. Please type your essay. *

If you would prefer to upload your essay, please make sure that it is a PDF or Word Document file.

MEDICAL RELEASE INFORMATION

The undersigned APPLICANT and the undersigned PARENTS or GUARDIANS of the applicant hereby agree that the applicant be permitted to travel to Berea, Ohio and live in a Rotary approved Residence Hall (dormitory) at Baldwin Wallace University as a participant of the Rotary Youth Leadership Awards (RYLA) Camp for 5 days.

IN CONSIDERATION of the acceptance and participation of the applicant in such program, the undersigned APPLICANT and his or her PARENTS or GUARDIANS, to the fullest extent permitted by law, hereby release and agree to save, hold harmless and indemnify, Baldwin Wallace University and members of their staff, and all members, officers, directors, committee members and employees of the host and sponsoring Rotary Clubs and District 6630 and of Rotary International, of and from all liability for any loss, property damage, personal injury or death, including such liability which may arise out of negligence of any such person or entities, which may be suffered or claimed by such applicant, parent or guardian during, or as a result of, the participation by the applicant in such Rotary Youth Leadership Awards Camp, including travel to and from camp.

WE GIVE PERMISSION for any operation, administration of anesthetic or blood transfusion which a medical practitioner may deem necessary or advisable for the treatment of any illness or injury suffered by the applicant.

WE AGREE that the Rotary Youth Leadership Awards Camp Director may sign on behalf of the applicant and his or her parents/guardian any and all emergency release documents for such treatment.

LAST NAME OF PARTICIPANT: *

FIRST NAME OF PARTICIPANT: *

LAST NAME OF 1st GUARDIAN: *

FIRST NAME OF 1st GUARDIAN: *

Emergency Phone Numbers of 1st Guardian: *

LAST NAME OF 2nd GUARDIAN:

FIRST NAME OF 2nd GUARDIAN:

Emergency Phone Numbers of 2nd Guardian:

DATE: *

If more information needs to be provided, please upload the document here.

CONSENT, RELEASE AND AUTHORIZATION (PHOTO RELEASE)

The undersigned participant, who resides at the address below, parent and natural guardian/custodial parent/legal guardian of the participant below, a minor, born on date below, hereby furnishes this, Consent, Release and Authorization to Rotary International District 6630, Rotary International, the Rotary Club of Berea, and the officers, trustees, directors and members of each (collectively “Rotary”) hereby permitting, and consenting to, releasing any claims resulting from, and authorizing, with regard to photographs, images, recordings, and video tapes made at the Rotary Youth Leadership Awards Conference (Camp RYLA) conducted in Berea, Ohio on Sunday, June 9, 2024, through Thursday, June 13, 2024, in which said minor participated, the following:

(A) Publication on the internet, including world wide web pages maintained by Rotary,
of pictures, video excerpts or sound or video recordings made at the Camp RYLA; and

(B) Publication of the names of the participants at Camp RYLA; and

A copy of this instrument shall be as effective as an original.

I HAVE READ, FULLY UNDERSTAND AND AGREE WITH ALL OF THE FOREGOING WITH THE MEDICAL RELEASE AND CONSENT, RELEASE AND AUTHORIZATION (GUARDIAN/PARENT MUST SIGN HERE) *

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I HAVE READ, FULLY UNDERSTAND AND AGREE WITH ALL OF THE FOREGOING WITH THE MEDICAL RELEASE AND CONSENT, RELEASE AND AUTHORIZATION (GUARDIAN/PARENT MUST SIGN HERE)

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