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Rotary District 7910 Youth Leadership Conference
RYLA CONFERENCE STUDENT APPLICATION FORM
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Dates: June 22-24, 2012
Place: Worcester State College, Worcester, MA
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- The entire cost of attending the RYLA Conference will be paid by your local Rotary Club.
- Successful applicants are required to attend the entire conference and must stay on campus until the end of the program on Sunday. Exceptions will not be made.
- Successful applicants will be required to provide a medical history and liability waivers.
- Application Deadline: January 6, 2012
- Mail hardcopy application to:
Rotary Club of Bedford
Att: Victor Tom
P.O. Box 414
Bedford, MA 01730
Email questions to vtom0@yahoo.com.
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Please type or print your responses neatly.
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Name:
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Age:
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Gender: q M q F
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Street Address:
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City:
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Zip:
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Phone #:
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Email Address:
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High School:
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Grade:
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School Reference: Phone:
Personal Reference: Phone:
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Interests, special talents, hobbies (music, sports, acting, writing, debating, etc.):
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Awards (civic and school):
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Extra-curricular Activities (school and community):
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Leadership Positions (in and out of school):
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Service to Community (in and out of school):
Rotary International's motto is SERVICE ABOVE SELF.
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What profession(s) are you considering after high school?
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Signed:
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Date:
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FOR CLUB USE ONLY
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Interview Date: ___ / ___ / ___ Time: ______________ AM / PM q PAR qALT
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Club Interviewer(s) _________________________ Rotary Club of ________________
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