Participant Registration Form

Application Instructions to fill out & mail in, if preferred:
1. Use black ink fine point pen. PRINT clearly. Applications that cannot be read will be rejected.
2. Be sure to answer every question – If a questions doesn’t apply, please answer “NA”.
3. Be sure to include the name of the Rotary Club sponsoring/paying for your participation.
4. Before completing the application be sure to review information on the rotary website at
www.rotarydistrict6920.org ( Use the QR code above). On the website click on Youth Services, then
Rotary Youth Leadership Awards). Please note – there are 6 additional forms (consents) required by
the Coastal College of Georgia/UGA System. You must complete and submit ALL
5. 2023 RYLA will be held at Coastal College of Georgia the weekend of June 8 – 11, 2023. The
program is based on full participation from Thursday, 3:00 pm to Sunday, 12:00 pm If you have
any conflict that would require you to leave the program for any reason – DO NOT REGISTER.
(Note: Be sure to check SAT and ACT test dates)
6. RYLA is open to high school rising Juniors & Seniors.
7. Acceptance into RYLA is not complete until payment has been received from the sponsoring Rotary
Club.
8. Return application, and all consent/waiver forms (you’ll have a total of 7 forms)
9. For Rotary Clubs – Make Check Payable to “Rotary District 6920- RYLA”
10. Additional questions contact RYLA registrar, information below.
11. No penalty for cancellations before April 15, 2023. After April 15, there are no refunds or credits.
Rotary Clubs MAY substitute a Student until June 1, 2023.

Be sure to download the Parental Consent Form and return HERE

Download printable form here

Name of Sponsoring Rotary Club: *

Student Name *

First

Last

Nickname *

Student Phone

Email *

Home Phone

T-Shirt Size

• Small
• Medium
• Large
• X Large
• XX Large

Do you have any physical or medical conditions that prevents you from actively participating in the RYLA?

• Yes
• No

If so, please explain

High School Information

Name of High School

Location of High School (Town)

Grade Level

Guidance Staff Name (optional)

Parent or Guardian Information

Father's Name

Mother's Name

Emergency Phone

Emergency Phone

Student Signature

Signature

Date

Electronic Signatures. Each party agrees that this Agreement and any other documents to be delivered in connection herewith may be electronically signed, and that any electronic signatures appearing on this Agreement or such other documents are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Apply for RYLA