The entire cost of attending the RYLA Conference will be paid by your local Rotary Club.

 Successful applicants will be required to provide a medical history and liability waivers.

 Attendees are required to attend the entire conference and must remain on campus until the 

 end of the program on Sunday. 

  Exceptions will not be made.

Please type or print your responses neatly.

Name:

Age: 

Gender:  M   F   

Street Address:

City: 

Zip:   

Phone #:

Email Address:

High School:

Grade: 

School Reference:                                                                 Phone:

Personal Reference:                                                               Phone:

Interests, special talents, hobbies (music, sports, acting, writing, debating, etc.):

Awards (civic and school): 

Extra-curricular Activities (school and community): 

Leadership Positions (in and out of school): 

Please submit applications to:

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Signed:

Date:

FOR CLUB USE ONLY

Interview Date:  ___ / ___ / ___  Time: ______________ AM / PM              PAR                                             ALT

Club Interviewer(s) _________________________ Rotary Club of ________________