Bedford Rotary - RYLA Rotary Youth Leadership Awards

Rotary District 7910 Youth Leadership Conference
RYLA CONFERENCE_STUDENT APPLICATION FORM

Dates: June 25-27, 2009
Place: Worcester State College, Worcester, MA

Applications are due by or before March 26, 2010 to Melinda Nicholson

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):

Service to Community (in and out of school): Rotary International’s motto is SERVICE ABOVE SELF.

What profession(s) are you considering after high school?

Please submit applications to:

Melinda Nicholson

978-344-5035
MELINDA.NICHOLSON@middlesexbank.com

Middlesex Savings Bank

168 Great Road, Bedford MA 01730

Fax-781-276-7875

Signed:

Date:

FOR CLUB USE ONLY

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

Club Interviewer(s) _________________________ Rotary Club of ________________