Rotary District 5180/5190 RYLA REGISTRATION FORM 2018

Transcription

1 Rotary District 5180/5190 RYLA REGISTRATION FORM 2018 ROTARY CLUB OF: ROTARY CLUB CONTACT: This form must be completed in full and signed by the student as well as a parent or legal guardian in multiple places. Incomplete forms will delay (or preclude) registration for RYLA. PLEASE PRINT CLEARLY. Student Name (Last) (First) (MI) Gender Student Home Address P.O. Box/Street City State ZIP Student Cell Phone Student Parent (Guardian) Name(s) Parent Home or Cell Phone Parent Student Birth Date T-Shirt Size High School (s, m, l, xl, xxl) (Enter 1, 2, 3 in the appropriate spaces below to indicate your session preference which is assigned on a first come, first served basis. We will notify you by welcome which session you will be assigned to) SESSION 1: June 17 22, 2018 SESSION 2: June 24-June 29, 2018 SESSION 3: July 8 July 13, 2018 Please read and sign the Student/Parent Commitment at the bottom of this page, (parents too!). One or both parents (or guardian/s) must sign both signature lines on page 2 of this form. Have your family physician complete the Doctor s Certificate on page 3 or attach a current copy of your school physical. Have your parents read and sign the Parental Authorization and Release on Page 4 Both the student and parent/s must read Page 5, Code of Conduct and sign where indicated. STUDENT/PARENT COMMITMENT I agree to arrive at RYLA by the designated start time (12 Noon on Sunday) and remain at RYLA until AFTER closing ceremonies on the last day, Friday (1 PM). The only EXCEPTIONS to this rule will be medical emergencies. Otherwise, NO EXCEPTIONS! I agree to FOLLOW all RYLA Rules as specified at the website and on page 5 of this application, and to travel to and from RYLA by transportation arranged by my sponsoring Rotary Club (or make special arrangements to travel to and from RYLA by other means, with my parent s permission and the consent of the RYLA Director). I certify that I am a JUNIOR in high school now, and will be a SENIOR this coming fall. I agree to, and understand that, as a participant, I may be photographed during RYLA, and that Rotary and its representatives may use RYLA photographs or images in publications or communications primarily to educate and promote awareness of RYLA and Rotary s commitment to youth. Student Signature: Date: Parent or Guardian Signature: Date: Page 1

2 MEDICAL STATEMENT STUDENT NAME ALLERGIES List all known (attach separate list if necessary) Describe reaction and management of the reaction. Medications Being Taken Please list ALL medications (including over-the-counter or nonprescription drugs) taken routinely. Bring enough medication to last the entire time at RYLA. Keep it in the original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration. MEDICATIONS (attach separate list if necessary) Dosage This student takes NO medications on a routine basis Please list any dietary restrictions below. Permission to Provide Necessary Treatment or Emergency Care: I hereby give permission to the medical personnel selected by the RYLA Director to order x-rays, routine tests, treatment, to release any records necessary for insurance purposes, and to provide or arrange necessary related transportation for me or my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the RYLA Director to secure and administer treatment, including hospitalization, for the person named above. Signature of Parent or Guardian Date Signature of Parent or Guardian Date Insurance Information Is the student covered by family medical/hospital insurance? Yes / No (circle one) If so, indicate carrier or plan name: Group # Carrier address Name of insured Relationship to student NOTE: In order to facilitate treatment in an emergency, please attach a photocopy of your health insurance card (front and back). Page 2

3 DOCTOR S CERTIFICATE (MUST BE COMPLETED FOR REGISTRATION TO BE COMPLETE) This is to certify that has been recently examined by me and was found: to be or not to be in good health and was found to have the following condition/s: He/she will will not be able to participate in RYLA activities and sports. His/her condition DOES DOES NOT require medications that are necessary at RYLA. Those medications are: Her/his latest TETANUS-TOXOID immunization was on. Please add any other pertinent information. DATE PHONE SIGNATURE PLEASE PRINT NAME ADDRESS NOTE: We will accept a current (this school year) copy of your school physical in lieu of this doctor s certificate. Please attach a copy and answer the following question: Are you aware of any condition expressed by a health care provider that would contradict the information contained in the school physical certificate? Yes No. Page 3

4 PARENTAL AUTHORIZATION AND RELEASE STUDENT NAME: PARENTAL AUTHORIZATION: I do voluntarily consent to my son s or daughter s good health and to participation in all RYLA activities, including the ropes course, to be held at Grizzly Creek Ranch, Portola, California on one of the afore mentioned dates. I assume responsibility for any medical or treatments fees or costs incurred directly or indirectly because of said minor s participation. I also authorize the representative(s) of Rotary Districts 5180/5190 to arrange for professional care and treatment in case of a medical emergency. I hereby give my permission to the physician selected by the Rotary representative to hospitalize, secure professional treatment for and/or to order injections, anesthesia, and/or surgery for the minor named above. RELEASE, ASSUMPTIONS OF RISK AND AGREEMENT TO HOLD HARMLESS In consideration of the sponsoring Rotary Club, Rotary International District 5180 and/or 5190, I permit my child to participate in RYLA and to engage in all related activities. I hereby assume the risk associated with participation and agree to hold the RYLA 5180/5190, Inc., the sponsoring Rotary Club, Rotary International Districts 5180 and 5190, their committees, employees, agents, representatives and volunteers harmless from any and all liabilities, actions, causes of action, claims or demand of any kind and nature whatsoever that may arise by or in connection with my child s participation in any activities related to RYLA, including the full day Ropes Challenge Course. The terms here shall serve as a release and the assumption of the risk for my child, his or her heirs, estate, executor, administrator, and assignees as well as members of my family. I grant Rotary Districts 5180 and 5190 and the sponsoring Rotary Club permission to use the image of the above-named minor for educational and promotional purposes. In addition, Rotary Districts 5180 and 5190 may contact the above-named minor regarding other Rotary programs, including, but not limited to, Interact, Rotaract, speech contest, musical performance contest and scholarship opportunities. Parent or Guardian Signature (Mother) Date Printed Name of Parent or Guardian (Mother) Parent or Guardian Signature (Father) Date Printed Name of Parent or Guardian (Father) Page 4

5 RYLA Rules and Code of Conduct All prescription and over-the-counter drugs must be in the possession of the RYLA Nurse and will be dispensed as needed. Students are not allowed to bring food of any kind into the cabins. It attracts wildlife. Issued T-shirt is to be worn at all times except for free time and evening activities. No alcohol or illegal drugs or recreational drugs are allowed on the premises. Smoking is not permitted at any time on the premises. Students are not permitted off site at any time without an adult escort. Cell phones, cameras, video recording devices and other internet connective devices are forbidden. No boy/girl co-mingling in cabins at any time. This means female students are allowed only in female designated cabins and males are only allowed in male designated cabins. I understand that if my SON/DAUGHTER is found to be in possession of liquor, drugs, tobacco products or unidentified medications, or otherwise violates the RYLA Rules, he/she will be sent home at my expense. As a parent and/or legal guardian, I remain legally responsible for any actions taken by the above-named student. RYLA Non-Discrimination Policy RYLA is committed to providing all students with a safe and supportive environment free from discrimination on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, or sexual orientation in all of its activities and operations. RYLA Youth Protection Policy A complete copy of the 5180/5190 Youth Protection Policy is available upon request. Signed (Student) Date Signed (Parent/Guardian) Date Page 5