Rotary District 7850 Ryla Registration Form (4 Pages)

ROTARY DISTRICT 7850 RYLA REGISTRATION FORM (4 PAGES)

Congratulations! You have been awarded a scholarship to attend a youth leadership seminar, the Rotary Youth Leadership Awards, held in Lyndonville, Vermont on Friday, June 22 to Sunday, June 24, 2012. Your parent or legal guardian needs to co-sign your three (3) release forms and the consent for medical treatment if it would be necessary. We apologize for the duplicate questions. They are required to meet the requirements of Rotary and our RYLA partners: Lyndon State College and the Vermont National Guard. Thanks in advance for filling these forms in completely and legibility. (PLEASE PRINT)

RYLA Participant Information

______

Last NameFirst Name Last Name Middle Initial Sex (M/F)

______Mailing Address City / Town State (Province) Zip+4 (Postal) Code

______S______

Name of School Attending in SeptemberCity/TownGrade

______

Home PhoneStudent Cell Phone

______

Student E-Mail Address

Date of Birth: M______D ______Year ______

______

Name of Student’s Sponsoring Rotary Club

Have you ever participated in any of the following other Rotary programs (Please check all that apply):

____Interact____Speech Contest____Polio Fundraiser

____Youth Study Exchange____Scholarship Winner____Service Project

____Other, Please Describe:

PARENT INFORMATION

______

Parent or Legal Guardian First Names Parent or Legal Guardian Last Names

______Relationship to Student (Mother, Father, Step-, Grandparent, Legal Guardian, Etc.)

______Mailing Address if Different from Student (please note SAME if the same, or place the name of the parent/legal guardian for whom it is different in the event parents live in different places)

______

Physical Address (if different from mailing, mark SAME if the same)

______Mother/Guardian #1 Home Phone Cell Phone Work Phone

______Father/Guardian #2 Home Phone Cell Phone Work Phone

______Parent or Legal Guardian Email Address

_____Yes/No: My parent(s)/legal guardian(s) is/are a member of Rotary

If yes, what club:______

EMERGENCY INFORMATION

______

In case of emergency, please contact (name(s) and relationship(s)

______During Daytime Hours, the best way to reach the person/people above is by:

______During Nighttime Hours, the best way to reach the person/people above is by:

If the Emergency Contact is not the above listed parent or legal guardian, please provide this person’s address/phone numbers/emails:

MEDICAL HISTORY

1) Do you have any allergic reactions (e.g., bee sting, drugs, foods, etc.? ( ) Yes No ( )

If yes, please explain:

2) Are you taking any prescribed medications? ( ) Yes ( ) No

If yes, what:

3) Do you have any chronic illness e.g., diabetes, epilepsy, asthma, etc? ( ) Yes ( ) No

If yes, what:

4) What is your current level of physical activity? (Very Active/Active/Average/Sedentary)

5) Do you have any conditions that might prevent you from any physical activities?

( ) Yes ( ) No If yes, please list:

6) Have you experienced any injuries (e.g., dislocations, severe sprains, torn ligaments, separations, etc. within the last three years? ( ) Yes ( ) No

If yes, list them, identify when the injuries occurred and the severity of the injury:

7) Have you fully recovered from this injury/these injuries?( ) Yes ( ) No

If no, please list the injury/injuries still in recovery and your current status:

8) Are you currently being treated by a physician or have been treated within the past year?

( ) Yes ( ) No If so, please explain:

9) Do you have any physical disabilities? ( ) Yes ( ) No If so, please explain:

10) Do you wear contact lenses?( ) Yes ( ) No

11) Have you had a tetanus shot? ( ) Yes (date if known______) ( ) No

12) Your family physician:

Name:

Address:

Phone #:

13) What health insurance coverage do you have and with which provider?

14) Please list your health insurance group & policy number:

15) Is there any other information you would like us to know? NO ( ) YES ( ):

Use rest of form:

Medical Authorization and Consent Release Form

I hereby authorize the 2012 RYLA Conference Chair or another RYLA Rotarian Volunteer to arrange for medical treatment and/or ambulance transport for my child, if in his/her opinion such treatment is deemed necessary, at any RYLA-related event in the 2011-2012 Rotary year. I further understand that in the event any medical treatment is deemed necessary, I will be contacted as soon as possible.

Signature of Parent or Legal Guardian:______

Print Name: ______

Date:______

Note: This form requires parent’s or guardian’s signature regardless of Student Age

Signature of Student:______

Print Name:______

Date:______

PARTICIPANT ASSUMPTION OF RISK – RELEASE OF ROTARY LIABILITY

The RYLA program provides goal oriented activities that offer participants an opportunity to explore new behaviors related to trust, teamwork, and leadership capabilities. Outdoor adventure activities are exciting, challenging, and both physically and mentally demanding. Some activities may be stressful and possibly hazardous. These activities may include field games, low elements (a few feet high that are constructed of rope, cable and wood), and high elements that require safety equipment, or rock climbing. All activities are supervised by instructors who have been specifically trained in the operation and safe practices of challenge courses, or rock climbing. The philosophy of “Challenge by Choice,” means that participants agree to choose their own level of challenge, and agree not to be coerced by instructors or other participants.

Rotary District 7850 has taken precautions to provide proper equipment and qualified instructors. It is impossible, however, to guarantee absolute safety. While it is the aim and responsibility of the program and instructors to provide you with an enjoyable, educational, and safe experience, you must realize that there is a degree of risk and personal responsibility for safety when you participate in adventure activities. You will receive instruction in safe up-to-date practices and safety techniques related to all elements and activities, and are supervised throughout the program. Participants are advised to call hazardous situations to the leader’s attention. Injuries can occur. By consenting to participate, you assume all risks incidental to use of the course and activities, including the possibility of bruises and other more serious injuries.

Signing this form indicates your recognition and understanding of the responsibilities and hazards inherent in your participation in the course.

I, the undersigned participant, understand that while attending the Rotary District 7850 “Rotary Youth Leadership Award (RYLA) Conference, I will have the opportunity to participate in the sports activities, as well as the “Rope Course” in small and large groups, and regular planned activities. I understand that parts of the activities of the conference may be physically or emotionally demanding. I affirm that my health is good, and that I am not under a physician’s care for any undisclosed condition that bears upon my fitness to participate in sports activities, including the “Rope Course.” I realize that I must assume the risk of physical injury that could result from any of these activities. I agree to assume all responsibility and risks involved in the program, and for myself and my heirs to release and hold harmless the Rotary Youth Leadership Awards Conference Coordinators, the Rotary Clubs, and Rotary District 7850 sponsoring and conducting the RYLA Conference, Rotary International and Lyndon State College form all claims and legal actions, whether for property damage, physical injury, or otherwise arising from my participation in the program.

I confirm with my signature that I have read this information. I understand my responsibility as a participant, and I assume the entire risks incidental to this adventure program. I have provided you with all the medical information that has been requested and agree to follow instructions and directions given by my instructors, and to act with good judgment.

______

Student’s Full Name (Print) (Signature)

______

Student SignatureDate

______

Name of Student’s Parent or Legal Guardian (Print)

______

Signature of Parent or Legal Guardian Date

VERMONT NATIONAL GUARDRELEASE OF

COUNTERDRUG TASK FORCELIABILITY FORM

In consideration for attending and participating in (circle one):

Community Summer Camps,

Mentoring,

Project Mountain,

Team Challenge,

Orienteering,

Ropes Course.

I freely accept and voluntarily assume ALL RISK of personal injury or death or property damage to include but not limited to all dangers that are inherent in this activity that are obvious and necessary. It is understood that these events will not include use of force but will involve outside and inside sport and/or physical activities to include but not limited to team challenge, land navigation, hiking, swimming, canoeing, running, jumping, climbing and lifting which have certain inherent and other dangers and risks.

I hereby release, remise, hold harmless, discharge and covenant not to sue the State of Vermont, Vermont National Guard, and in so far as applicable, the United States and the United States Armed Forces, and its agents, volunteers and employees from any and all liability for personal injury or death or property damage which results in any way from negligent actions and /or omissions of employees, volunteers and/or agents of the Vermont National Guard, the State of Vermont or the United States Armed Forces, arising out of the conditions on or about the premises and the facilities used for. (circle one):

Community Summer Camps,

Mentoring,

Project Mountain,

Team Challenge,

Orienteering,

Ropes Course

including but not limited to natural or man-made obstacles and its placement, visibility or condition or my participation in any activity during these events.

If I am signing on behalf of a minor, I hereby certify that I have full authority to act as his/her legal guardian and in that capacity. I understand that in case of injury or illness of a minor, I will be notified and understand that my child may be administered any emergency services as deemed necessary by emergency and hospital medical personnel.

I hereby agree to fully indemnify and hold the Vermont National Guard and the State of Vermont, and to the extent applicable the United States Armed Forces, harmless from any and all damages or losses or actions of any kind brought by any person, including the minor, which arises out of the participation in and attendance in the activities of the Counterdrug Task Force.

I understand that news media may be invited to view, photograph, record or film portions of the event, and may interview attendees. My child’s photograph, image, quote or voice maybe published, copyrighted, or otherwise used in news presentation.

Nothing in this release waives any right that my child or I have under the Federal Torts Claims Act. And, in the event of a claim, I will contact the Safety Officer at Camp Johnson, (802) 338-3000, for the proper forms and procedures for filing a claim.

I CERTIFY THAT I HAVE READ AND UNDERSTAND THIS DOCUMENTAND FREELY ENTER INTO THIS AGREEMENT.

Participants Name: ______

Participant’s Signature: ______

Parent/Guardian Signature is required if student is less than 18:

Parent/Guardian Name: ______

Parent/Guardian Signature: ______

Date:

Emergency Contact Information:

Person to contact in case of emergency______

Telephone Numbers: Work ______Home______

Medical Information:

List any information about medical conditions that may affect your child’s participation in any of these events ______

ROTARY DISTRICT 7850

Rotary Youth Leadership Award (RYLA)

Marketing Release

Unless Rotary District 7850 is otherwise notified in writing, I allow my child/ward to appear in photographs or video images solely taken for the purpose of promoting the Rotary Youth Leadership Awards. Rotary District 7850 has the right to use these images, including audio and video, in perpetuity in any form or medium, print or electronic.

Signed: ______

(Parent or Guardian) (Date)

Print Name:______

Signed: ______

(Student) (Date)

Print Name:______

Page | 1 of 9