Form

Full Name*

First Name Last Name

Preferred Name

E-mail*

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Gender*

Birth Date*

Month Day Year

Phone Number*

- Area Code Phone Number

Mobile No.*

Photo*

Marital Status*

T-Shirts Size*

Emergency Contact Name*

Emergency Contact Number*

Emergency Contact Relationship*

Tell us about yourself (100 words)*

Hobbies, Interest and Special Skills*

Are you Employed? If So, Please describe your Job. (100 Words)*

Relevant Qualifications, Dipilomas or Certificates*

List all membership to clubs and/or Groups*

What Leadership roles to you hold in the above listed groups.*

Have you any special dietary or medical requirements, allergies or other special requirement for any other kind of care that we should be aware of?*

Do you play a musical instrument*

If so, What ?

Copy the Unique Code*

CONDITIONS OF ACCEPTANCE BY APPLICANT

I hereby apply to be considered to participate in the Rotary Youth Leadership Awards Seminar program and have read and agree to the following conditions of Acceptance and Participation:

I will be at least 18 years of age on 1 January 2012 and also under 27 years of age on that date.

I will be available to attend the full week program on the nominated dates.

I acknowledge that this is a residential course and no "leave passes" will be issued without the express permission of the seminar director or the seminar director’s assignee.

I understand that as a condition of Rotary’s hire of the Elanora Centre facilities that illicit drugs, illegal substances and alcohol are not permitted on site, and that use or consumption will result in expulsion from the course without refund of fees. Should there be a need for me to take any scheduled medication, properly prescribed by a medical practitioner, and not otherwise previously declared in this application, then I will inform the seminar director of this requirement.

I understand that transportation to and from the venue will be undertaken by my sponsoring Rotary Club and that private vehicles are prohibited on site.

I understand that the program may include, but is not restricted to, such activities as abseiling, canoeing, high ropes, bush walking, rock climbing, swimming, archery, physical team building activities and forms of sporting events.

I have the right to decline to participate in any programmed activity but, in the event of my participation, I acknowledge that whilst every care will be taken by the activity leaders, including those employees, agents and servants of the Elanora Centre, and any other person nominated, who may organise, arrange and conduct those activities, I expressly agree to hold harmless and do hereby indemnify Rotary District 9680, the organising Rotary Clubs, its officers, members, servants, employees and agents from any and all actions, suits, damages, claims and demands arising out of accident or injury or illness which may befall or occur as a result of my participation in, during, or as a result of any activity or function undertaken by me in connection with the Rotary Youth Leadership Awards program, or when travelling to or from such activity or function including transportation to and from the site. further authorise any officer, member, servant or agent of Rotary District 9680 or Rotary Club, including those employees, agents or servants of the Elanora Centre, in the event of any injury, accident or illness arising from any cause whatsoever to obtain such medical assistance or treatment that is deemed appropriate, and to engage any doctor, nurse or an appropriate member of an emergency service and arrange any hospital accommodation as is deemed appropriate.

I agree to reimburse the said Rotary District 9680, Rotary Club, employees, agents and servants of the Elanora Centre on demand, all such expenses associated with the treatment of any accident, injury or illness, including but not restricted to doctors, nurses, hospital fees and transportation.

I agree to follow any reasonable direction given me by the said Rotary Club, its agents or servants, including those employees, agents or servants of the Elanora Centre, in the event of any safety procedures being implemented to protect and safeguard my well-being.

I agree that any photographs or images taken at the camp may be used in promotional material for future camps relating to RYLA.

I acknowledge the information I have provided with respect to my application is true and correct to the best of my knowledge, and authorise the release of information to the appropriate authority in the event it becomes necessary to do so.

RYLA Application form