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Application Form - RYLA LAKELSE District 5040
(Grades 8-10)
Terrace, BC – July 2-5, 2015
INSTRUCTIONS CHECKLIST: ALL 4 TICKS MANDATORY to COMPLETE APPLICATION
Please note:
ENTRY
DEADLINE
June 14, 2015
Are all 4 pages LEGIBLE, SIGNED and COMPLETELY FILLED?
Is this Application Scanned and Sent by Email?
Is this Original Hard Copy & Signed Form and payment ALSO MAILED?
Mailed Original and payment will be RECEIVED BEFORE event?
Email registration form:
[email protected]
Tel: 250.877.9366
Mail original and payment to:
Manuela Krisinger, Treasurer
c/o Rotary Club of Terrace
Box 541
Terrace, BC, V8G 4B5
Sponsored by the Rotary Club of:
Club Contact name:
First name:
Tel No. and Email:
Surname:
Address:
Gender (M/F):
City:
Postcode:
Home Phone:
Cellphone/Other:
T-shirt size: S M L XL XXL
Age:
Date of Birth: (dd/mm/yyyy):
Email:
Preferred first name:
School attended:
Please provide the following information (use a separate sheet of paper if you need more space):


What you hope to gain by attending RYLA
Your activities/achievements related to Leadership such as volunteer involvement, clubs, positions held and
other similar activities/achievements
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Medical Waiver Form - RYLA LAKELSE
(in case of emergency)
Terrace, BC – July 2-5, 2015
Name (first, last):
Address:
Parent/Guardian Name:
Emergency Contact Name:
Phone Number:
Family Physician Name:
Phone Number:
Personal Health Number:
Special Considerations:
Vegetarian?
(Y/N):
Food Allergies?
(Y/N):
Details:
Other Allergies? (Y/N):
Details:
Administered Medicine? (Y/N):
Details and dosage:
Medical History? (Y/N):
(e.g. diabetes, bee stings etc)
Details:
Do you have any physical issues that would prevent you from participating in routine physical activities? (Y/N):
Details:
Indemnification and release:
I hereby represent that I have no physical restriction that would prohibit my participation in the events at RYLA. I hereby agree to
participate in the activities of the RYLA program sponsored by Rotary International District 5040 Inc.
Participant's Signature: _________________________
Date: ________
Parent/Guardian Signature: __________________________
Rotary International is committed to protect the privacy of your personal information and
to comply with the Privacy Act, BC's privacy laws and the Personal Information Protection
Act. The information supplied in this document will be used for the sole purpose of
ensuring that appropriate medical help is made available should the need arise. This
information will not be divulged to any 3rd party, or shared in any other way, by the
District 5040 RYLA committee.
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District 5040 Rotary Youth Leadership Awards
Terrace, BC – July 2-5, 2015
PHOTOGRAPHY/VIDEO/INTERNET CONSENT FORM
I, _______________________________________________, am the parent/legal guardian of
_______________________________________
I understand that during the RYLA program, photographs and video recordings will be taken
and I hereby give my consent to ROTARY INTERNATIONAL to use these photographs and video
in ROTARY INTERNATIONAL's internet based
I also understand that photographs and video recordings taken by RYLA volunteer staff and
fellow participants may be posted on the Internet, through entities such as Facebook and
MySpace, which postings may be widely accessible, thus ROTARY INTERNATIONAL, ROTARY
INTERNATIONAL DISTRICT 5040 Inc., and the volunteer organizers and staff of the RYLA
program cannot guarantee privacy or control the public's access to these photographs or
video recordings.
Signed at (city) ___________________________, British Columbia, on ______________________(Day, Month?Year):_________
Signature:
Print name:
Address:
RYLA LAKELSE
ACKNOWLEDGEMENT OF RISKS AND AGREEMENT TO HOLD HARMLESS
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I, ___________________________, parent/legal guardian of ________________________________, recognize that my dependent will
be involved in outdoor actvities on a trip organized by Rotary International District 5040 Inc. - Rotary Youth Leadership Awards. Activities
involved in this trip may include (but are not limited to) hiking, ropes courses, sports and games, as well as various leadership activities
and team building exercises.
I understand that outdoor activities present to the participant a wide variety of risks and conditions. These conditions may include, but
are not limited to uneven terrain, changeable weather conditions, animal and plant life, and use of assorted vehicles, gear and
equipment including various types of safety gear. I understand that such risks simply cannot be eliminated without jeopardizing the
essential qualities of the activity.
I understand that the organization is not always equipped with the skills, training, equipment and insurance necessary to undertake
these types of educational activities, and will need to enlist the aid of outside agencies that embody and abide by high professional
standards within their industry.
I acknowledge that the outside agencies involved in this particular education trip hosted on the property of Nicole and Carman Hendry
have both read and sanctioned this agreement.
I expressly agree and promise to accept and assume all of the risks existing in this activity that are in my control. My dependent does not
have to participate in the activities if he/she does not feel comfortable or confident in doing so. I certify that my dependent has no
medical or physical conditions that could interfere with safety, or else I am willing to assume - and bear the costs of - all risks that may
be created, directly or indirectly, by any such condition.
I understand that both the organization and the above-mentioned outside agencies will approach this trip with both care and planning.
While the trip is underway, they will endeavour to instruct, protect and care for the well-being of my dependent as I would in their
place, including making decisions regarding the medical care of my dependent. I also understand that, following all trip activities, they
will continue to maintain professional standards of behaviour regarding my dependent.
I understand that my dependent will be expected to uphold the standards of behaviour expected of him/her by the organization. He/she
will be expected to listen to and honour any request, suggestion, advise or rule given by the staff, employees of the outside agencies
selected by the organization and other supervising adults on the trip, with the understanding that this is in the best interest of all
participants. He/she will be expected to act with responsibility and care for him/herself and for others on the trip.
I understand that the organization and camp staff will take reasonable steps to prevent injuries to participants. Some degree of risk is
inherent in the nature of this activity and may occur without fault on the part of the participant, organization, or hosts Nicole and
Carman Hendry. By allowing my dependent to participate in this activity, I am agreeing that the activity described above is suitable for
my dependent, and that there is a risk of injury associated with the activity.
I am aware that there are risks involved in this program, and have decided that I am prepared to allow my dependent to participate in
the program and all activities involved in the program. I am content to allow them to proceed on the trip as they wish.
I have read this agreement and have understood its nature and its contents. Please allow my dependant to participate.
Signature of parent/guardian:
Address
City/Prov
Home Phone:
Work/Cell#:
Emergency Contact:
Relationship:
Please list any health conditions or medical issues that we ought
to be aware of (Previous injuries, medications, allergies, dietary
needs etc.)
Print name and date:
PC:
Medical Plan #:
Phone#:
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