Rotary Youth Leadership Awards

May 14-16, 2015

Rotary District 7950

HEALTH HISTORY AND CONSENT FORM – ADULT OR CHILD

District 7950 RYLA Student Forms

Please complete and send to RYLA Registrar Lew Gordon by April 1st, 2015

Lew Gordon, RYLA Registrar, 11 Mashpee Dr., North Attleboro, MA 02760 or email to

Forms to submit:

  • RYLA 2015 Health History Form
  • RYLA 2015 Hold Harmless Agreement
  • RYLA 2015 Quick – Emergency Information Form
  • RYLA 2015 Media Release Form

As a RYLArian, you are aboutto take partin a leadership training program that includes a challenge (“ropes”) course experience offered through Rotary District 7950 S.E. Massachusetts, Cape Cod & the Islands, & Rhode Island,The Cape Cod & Islands CouncilBSA, & Cape Cod Sea Camps Brewster.

While participating in the activities you willundertake a wide variety of physicaland mentalchallenges thatare comparable to activities with which you may be more familiar. Some of the time, you willbe engaged in activity of “moderate exertion,” which is comparable to normalwalking, golfing on foot, raking leaves, calisthenics, or slow dancing. For shortperiods of time, you willbe engaged in activity of “vigorous exertion,” which is comparable to fastwalking, slow jogging, heavy gardening, or shoveling snow.

If any of the above activities are difficultfor you, discuss your participation in the activity with your physician. If these are activities in which you regularly engage withoutdifficulty, you should be fitfor participation in the program.

The following are specific medicalconditions aboutwhich participants should always seek the advice of a physician before participating in the activity:

  • Pregnancy (climbing harness can injure uterus)
  • Kidney or liver transplant (climbing harness can injure organ)
  • Healing fracture or jointinjury (should be cleared by treating physician)
  • Recentsurgery (should be cleared by treating physician)
  • Down Syndrome (should have X-ray check for neck instability, as per recommendation of the SpecialOlympics)

HEALTH HISTORY

Name:
First Middle Last
Telephone: / Home / Work
Mobile / Work
Personalphysician / Telephone:
Name
In case of emergency, please contact: / Telephone:
Name
Specialdietary considerations:
Listknown allergies:
Listrequired medications:
If you are allergic to insect stings, do you have an insect sting kit (e.g., EpiPen)?
Do you wear contactlenses? / Are you pregnant?
Have you had or do you now have (circle or bold and redden if yes): / Heartattack / Diabetes / Asthma
Angina / Epilepsy / Chestpains / Drug reactions / High blood pressure / Heartmurmur
If you answered “yes” to any of the above, explain and include date:
Do you have any dietary restrictions or food allergies?
Do you have any other medicalconditions thatwe should be aware of?
Use the back of this form or second page for additional information if necessary

** A completed Health History form including Emergency Contact information is required for attendance at RYLA 2014

Please complete this form and mail to Lew Gordon, RYLA Registrar, 11 Mashpee Dr., North Attleboro, MA 02760 or email to

Permission to Treat

I hereby give Paul Nicol as co-chair of RYLA permission to have my son/daughter ______treated for any injury or medical condition that may occur while participating in the RYLA program. I am enclosing a copy of my insurance card for my son/daughter front and back with this consent.

Signature of Parent/Guardian: ______Date: ______

No student will be denied the opportunity to attend RYLA if they do not have health insurance. Insurance will be covered by the Rotary Liability Insurance Policy.

Please complete this form and mail to Lew Gordon, RYLA Registrar, 11 Mashpee Dr., North Attleboro, MA 02760 or email to . This form is due to the Registrar by April 1st, 2015.

Rotary Youth Leadership Awards

May 14-16, 2015

Rotary District 7950

HOLD HARMLESS AGREEMENT

I understand thatparticipation in the activities involves a certain degree of risk thatcould resultin injury or death. In consideration of the benefits to be derived, after carefully considering the risk involved, and in view of the factthatthe Rotary Youth Leadership Awards program of Rotary International /District 7950, The Cape Cod & Islands CouncilBSA, & Cape Cod Sea Camps, Brewster are groups in which membership is voluntary, I have carefully considered the risk involved and have given consentfor myself (or my son or daughter) to participate in the activity, and waive allclaims I or we may have against Rotary International, District 7950, the District RYLA Committee, The Cape Cod & Islands CouncilBSA, & Cape Cod Sea Camps, Brewster, the activity coordinators, and allemployees, volunteers, related parties, or other organizations associated with the activities.

I am notunder the influence of any chemicalsubstance, including alcohol. Understanding thatany physicalactivity involves a risk of injury, I understand thatmy participation in the activity is entirely voluntary. I release Rotary International, District 7950, the District RYLA Committee, the activity coordinators, and allemployees, volunteers, related parties, or other organizations associated with the activities from any and allclaims or liability arising outof this participation. This release does not, however, apply to any harm caused by negligence or willful misconductof Rotary District 7950, & the Cape Cod & Islands CouncilBSA or other individuals involved in organizing the event.

In case of emergency involving my child, I understand every effortwillbe made to contactme. In the eventI cannotbe reached, I hereby give my permission to the physician selected by the adultleader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child.

Participant’s signature*______Date ______

*If the participantis under age 18, his or her parentor guardian mustalso sign below:

Parent’s or guardian’s signature______Date ______

This form must be completed and signed by both the student and a parent or guardian for the student to participate in RYLA 2014.

Please complete this form and mail to:

Lew Gordon, RYLA Registrar, 11 Mashpee Dr., North Attleboro, MA 02760 or email to:

This form is due to the Registrar by April1st, 2015

Rotary Youth Leadership Awards

May 14-16, 2015

Rotary District 7950

Quick – Emergency Information Form

Please have your son / daughter hand this “Easy to Read” form in at Registration at RYLA 2013, April 19th at Cape Code Sea Camps.

It would be prudent for your son / daughter to bring a copy of any medical insurance coverage documentation he / she might need in the case of an emergency.

We have filled-in, signed, and returned the RYLA Health History form for my son / daughter

RYLArian’s Name: ______

Parent Signature: ______

In case of emergency, please contact: ______

Relationship to RYLArian: ______

Phone #1 ______

Phone #2 ______

In case we cannot reach the person you named above, who would be an alternate contact?

______

Phone #1 ______

Phone #2 ______

Are there any other pertinent medical details you feel it would be important for us to know in order to properly care for your teenager in case of an emergency?

Thank You!

Please complete this form and mail to:

Lew Gordon, RYLA Registrar, 11 Mashpee Dr., North Attleboro, MA 02760, or email to

This form is due to the Registrar by April1st, 2015.

Rotary Youth Leadership Awards

May 14-16, 2015

Rotary District 7950

Media Release Form

YES _ / _ NO I give my permission for my son or daughter’s picture (headshot) to be included in a RYLA 2014 Directory, which mayl be produced and distributed to attendees of the leadership weekend as well as the Rotary Clubs that sponsored the RYLArians. I, also, give my permission for my son or daughter’s contact information and a brief bio to be included in the RYLA 2014 Directory.

YES _ / _NO I give my permission for my son or daughter, to be photographed and/or videotaped by the media and representatives of Rotary District 7950 in conjunction with activities associated with Rotary International, Rotary Youth Leadership Awards program. I hereby transfer to Rotary District 7950 all copyright and other interests in photographs and/or videotape taken on between April 19th and April 21st, 2014. I also hereby grant royalty-free permission, including nonexclusive world rights in all languages, to reproduce in all formats including but not limited to print, electronic, and/or CD / DVD media, to reproduce and include my son’s or daughter’s likeness for promotional purposes of Rotary International, Rotary Youth Leadership Awards program.*

Signature: ______

(parent or legal guardian)

This form must be returned to the RYLA committee by April 1st, 2015.

Mail To:Lew Gordon, RYLA Registrar, 11 Mashpee Dr., North Attleboro, MA 02760 or email to:

* Rotary District 7950 is planning to take photographs and video of individuals and activities during the RYLA weekend event on Cape Cod. We are hoping to produce print and video materials that we will use to promote RYLA in our District and throughout the Rotary world. In order to create such a production we need your permission to take the photographs prior to the event. We will also be giving each student a Directory with bio information on the weekend’s participants so that the RYLArians can stay connected after the event.