Rotary Youth Leadership Awards 2018 Sat 17 th to Fri 23 rd February 2018 - Capricorn Caves, Rockhampton APPLICATION FORM Note to Applicants Thank you for your interest in attending the 2018 Rotary Youth Leadership Awards program (RYLA). The following are some key points to consider prior to submitting your completed application form. Acceptance into RYLA is usually based on sponsorship by a local Rotary Club. If you aren t in contact with one, we can assist you in seeking sponsorship. Final decisions are at the discretion of individual Rotary Clubs As Rotary Clubs invest significantly in sending applicants to RYLA, it is extremely important that you are able to attend the program for the entire duration (dates above). Prior to submitting your application please ensure you are able to take holidays from work and schedule the time away Please make sure you read and understand all aspects of this application form and ensure the information you provide is accurate If you have any questions do not hesitate to email us at ryla9570@gmail.com or call 0439 796 903 SECTION 1: YOUR DETAILS Date of Birth Preferred Name Postal Address Gender Normal Shirt Size MENS LADIES Town / City / Suburb Postcode Email Address How did you find out about RYLA? SECTION 2: EMERGENCY CONTACTS Primary Contact Relationship to you Secondary Contact (If primary contact is not able to be contacted) Relationship to you Page 1 of 5
SECTION 3: ABOUT YOU We re not looking for a list of everything on your resume, instead we want to know what you re passionate about and what experiences you can share with others participating in RYLA. Please limit your responses to 150 words. PLEASE TE: Your responses will T affect your application. What are you currently doing in relation to work or study? Are you involved in volunteer or other community work? What would you hope to get out of attending RYLA? During the week you will be interacting with other participants and program content is varied and involves long days. You can expect to have your views and opinions challenged. How do you think you will adapt to this environment? Phones and other devices will not be permitted during the program A crucial component of RYLA is the time away from everyday life. There is no access to email, internet or TV and participants are strongly encouraged not to bring their mobile phone. Participants who elect to bring their mobile phones will only be permitted to access their phones after 10pm each evening. Is this something you are happy to adhere to? SECTION 4: MEDICARE / HEALTH INSURANCE Regular doctor Phone number Year of last tetanus injection Medicare # Private health provider Membership # Other relevant details Page 2 of 5
SECTION 5: SPECIAL NEEDS AND MEDICAL DETAILS RYLA seeks to cater for individuals of all abilities, cultural and religious backgrounds and any dietary or medical need. Please complete this section as accurately as possible. The information will be retained by the RYLA Chair and only shared with relevant RYLA leaders for use only as required to assist you during RYLA. All information is treated with the strictest of confidence. SPECIAL NEEDS: Do you have any conditions that require special consideration during RYLA i.e. hearing or sight impairment, sprains, strains, injuries or other? PHYSICAL ACTIVITY: RYLA involves a range of physical activities. Are there any activities that you would be unable to participate in? DIETARY REQUIREMENTS: Do you have any special dietary requirements? ALLERGIES: Do you have any allergies, medication, food or other? ALLERGY TREATMENT: Do you have any medication to assist with treatment of an allergy? OTHER MEDICATION: Are you currently required to take any medication? PAIN MEDICATION: Can you take standard pain medication i.e. Panadol, Nurofen, Aspirin? Please note: If yes, you will provided the medication to administer yourself. Please provide details Page 3 of 5
SECTION 6: RYLA RULES AND GUIDELINES The RYLA team tries to make the program as fun and as enjoyable as possible, while ensuring the comfort and safety of all participants. To help achieve this we ask participants to adhere to the rules and guidelines outlined below. Breach of these may result in you being asked to leave the program. 1. Participants must attend and adhere to meal and session times. 2. No illicit drugs or alcohol are to be used or taken to RYLA. 3. Participants will be allocated gender segregated rooms and must respect the privacy of others at all times. 4. Participants should bring all personal items required for the week. Leaders will make limited trips to Rockhampton for supplies and if you need to purchase anything, it will be at your cost. 5. There are minimum requirements expected for cleaning and general housekeeping. 6. Participants must abide by all the rules and guidelines of the Lodge and Camp site. 7. phones will not be permitted under any circumstance during the program (emergency phone numbers will be provided to pass on to family and friends in case of emergency). phone reception is limited at the venue however there is a landline on-site. 8. Participants are permitted to bring their vehicle to RYLA however attendees will not be able to leave the site for the duration of the camp. Failure to adhere to this may result in termination from the program. 9. Participants who engage in misconduct during the program may be asked to leave. 10. Participants are solely responsible for their own personal items. SECTION 7: APPLICANT AGREEMENT Read this section carefully and sign only if you agree with each item. 1. I confirm that all information provided within this document is complete and accurate. 2. I will be positive, respectful and actively participate in all aspects of the RYLA program. 3. I commit to adhere to all rules and guidelines of RYLA and the venue and will follow all reasonable instructions. 4. I agree to visit my Sponsoring Rotary Club after the program to tell them about my experience. 5. I hereby absolutely release and discharge Rotary District 9570 or Rotary International and all its employees, agents and voluntary helpers from and against all claims whatsoever arising out of death, personal injury or loss or damage to personal property that the applicant may suffer or sustain in the course of the program period. 6. I agree that in the event of injury to myself where I am not able to make a decision, you are authorised to obtain, at my expense, any medical, ambulance or like service that you in your absolute discretion think necessary. 7. I confirm that I will arrange my own transport to and from the program. NAME OF APPLICANT SIGNATURE OF APPLICANT DATE SECTION 8: MEDIA RELEASE Read this section carefully and sign only if you agree. I authorise Rotary District 9570, the RYLA Committee and its authorised Agents to use any photographs, video footage & other electronic media taken that may include myself on the RYLA program as promotional material for the purposes of promoting the activities of Rotary. I understand this may include, but is not limited to, printed brochures, press releases, website and social media, promotions, newsletters & testimonials. NAME OF APPLICANT SIGNATURE OF APPLICANT DATE Page 4 of 5
SECTION 9: FINDING A SPONSOR ROTARY CLUB Are you currently in contact with a Rotary Club that has indicated interest in sponsoring you? Name of club Name of your club contact If, don t stress. Your application will be included in a 'pool' of applicants and we will seek to find a Rotary club to sponsor you on your behalf. Send this complete, signed form to ryla9570@gmail.com If, please pass this complete, signed form to the Rotary Club you have been speaking with. THE SECTION BELOW IS TO BE COMPLETED BY YOUR SPONSOR ROTARY CLUB SECTION 10: ROTARY CLUB AGREEMENT We, the Rotary Club recorded below, nominate the person named within this application to attend the 2018 RYLA Program to be held from Saturday 17 th of February 2018 to Friday 23 rd of February 2018 at the Capricorn Caves in Rockhampton. Our club agrees that should our applicant be accepted, we undertake to make payment of $800.00 inc. GST to cover the program costs for this participant prior to February 2018. (Upon acceptance of your nominee, your club will be issued an invoice from the District Treasurer) Name of Rotary Club Name of Club Contact ROTARY CLUB SECRETARY / PRESIDENT SIGNATURE OF AUTHORISED PERSON DATE FOR FURTHER INFORMATION OR TO SUBMIT THE APPLICATION Blair Felsch - District RYLA Chair - EMAIL: ryla9570@gmail.com PHONE: 0439 796 903 Page 5 of 5