rotary youth
leadership
awards

Camp RYLA
DEC 5 - 9,

Camp RYLA Applicatioins Submission Cover Letter

Students: Please complete this form and return to your sponsoring Rotary Club along with the documents listed below.

Name

Statement of leadership Responsibility - Completed and signed by all parties concerned.
Camp RYLA Code of Conduct - Completed and signed by all parties concerned
Parent/Guardian Informed Consent - Completed and signed by all parties concerned.

Florida Elks youth Camp informed Consent/Medical Information

 (If Possible - a copy of parents insurance card with company Name of and Policy #.)
 Completed and signed.

Florida Elks Youth Camp Rope Challenge Course
Completed and signed by all parties concerned.

To Be Reviewed By Counselor

Is this a Primary Candidate of Alternate Candidate
Rotary Club of
I have reviewed the above documents for completeness.
Submitted by: Date
Phone# E-Mail address

Please mail all the above completed documents to:

Camp RYLA
DEC 5 - 9,

Instructions for completion of Camp RYLA attendee's application.

Camp RYLA will be a life changing experience for you.
To attend Camp RYLA, it is important that you read and follow the instructions
below in completing and submitting your application.

All applicable information must be filled in. If a section calls for
information that is not applicable to you, please insert "N/A".

If you are taking any prescription medication you must furnish the name
of the medication, the dosage and how often it is taken.

You must turn in your completed, signed application to
your sponsoring Rotary Club.

If you have any questions regarding Camp RYLA please contact your sponsering Rotary Club.

If you do not have a sponsoring Rotary club please contact Camp RYLA Chair

Eric Gordon RYLA Chair
561-308-9305 (cell)
eric@ericgordon.com

Rotary District 6930
Camp RYLA
CODE OF CONDUCT

The physical, secual or emotional abuse of harassment of any student will not be tolerated.All allegations of abuse or harassment will be taken seriously. the safety and well-being of students will always be the first priority.

Definitions:
Sexual abuse: Sexual abuse refers to engaging in implicit or explicit sexual acts with a student or forcing or encouraging a student to engage in implicit or explicit acts alone or with another person of any age. Of the same sex or opposite sex. Additional examples of sexual abuse could include, but are not limited to: non-touching offenses, indecent exposure, exposing a child to secual or pornographic material.

Sexual harassment: Sexual harassment refers to sexual advances, requests for sexual favors or verbal or physical conduct of a sexual nature. in some cases, sexual harassment precedes sexual abuse and is a technique used by sexual predators to desensitize or groom their victims. Examples or sexual harassment could include, but are not limited to: sexual advance, sexual epithets, jokes, written or oral references to sexual conduct, gossip regardings one's sex life, and comment about an individual's sexual activity, deficiencies or prowess: verbal abuse of a sexual nature: displaying sexually suggestive objects, pictures or drawings: an sexual leering or whistling, any inappropriate physical contact such as bruising or touching, obscene lariguage or gestures and suggestive or insulting comments.

If sexual abuse or harassment should occur, the Camp RYLA committee will follow the RYLA Sexual Abuse and Harassment Allegations Reporting Guidelines as estabblished by Rotary International.

I have read and agree to conform to the above code of conduct, conditions and expectations. Should my conduct be considered unacceptable at any time in the opinion of the Camp RYLA Committee. I undersand that I will be dismissed from Camp RYLA and sent home at my parents or guardians expence.

STATMENT OF LEADERSHIP RESPONSIBILITY

UNDERSTAND THAT:

1. I have made a commitment to attend Camp RYLA from Decemeber 5 - 9, and will notify my sponsoring Rotary Club immediately if a conflict arises.
2. I may not arrive late or leave RYLA earlier than scheduled.
3. I will be on time and attend all meals meetings and activities scheduled for my group.
4. I have a duty and a responsibility as a leader to report immediately any inappropriate acts or conduct that i personally observe by and or between my fellow Camp RYLA attendees to the Camp RYLA Chair.
5. I MUST SLEEP IN THE CABIN WHICH IAM ASSIGNED. Lights out is at the scheduled time. When lights are turned off I will be quiet thereafter and not leave my cabin unless in an emergency.
6. Males are not allowed in female cabins and vice-versa.
7. Phones are permitted only during scheduled recreation times breaks or while in your cabin.
8. Recreation activities are limited to those periods of the day and evening scheduled.
9. If any person is injured or becomes ill, I WILL NOT MOVE THEM. I will contact a member of the Camp RYLA Committee immediately.
10. I will report any damage or breakage immediately to the CAMP RYLA Committee.
11. SMOKING IS PROHIBITED. No exceptions.
12. ALL MEDICATIONS, whether prescribed or "over the counter", must be identified on the container. unidentified medications, alcohol, weapons, or tobacco products found in the possession of any student will be confiscated and the student will be expelled from Camp RYLA. It is uner RN dicrection to dispose of any medications.
13. Foul or abusive language (including anything of a discriminatory nature) will not be tolerated, nor will physical violence or threats of any kind be allowed. If I observe such behavior, it will be my responsibility to contact a member of the Camp RYLA Committee immediately.
14. Any sexual or lewd misconduct by and/or between myself and other participants will be considered unacceptable behavior.
15. I may not leave the camp area without the permission of the Camp RYLA Committee Chair.
16. Confidentiality is important. Anything shared by a member of your group should remain in that group. However, the Camp RYLA committee members are mandated by law to report any suicide or abuse issues to the proper authorities.
17. I am to conduct myself in all sessions, in all activities, in the dining hall, in classrooms, in sports, and in my cabin in a manner which will bring credit to myself, my school, my sponsoring Rotary Club and my family, and in a manner which will not cause injury to another person.

I have read the Statement of Leadership Responsibility and do hereby agree and commit to honoring them.

SHOULD MY CONDUCT BE CONSIDERED UNACCEPTABLE AT ANY TIME BY THE DISCRETION OF THE CAMP RYLA COMMITTEE, OR SHOULD I TRANSGRESS ANY OF THE CODES STATED ABOVE, I UNDERSTAND THAT I WILL BE DISMISSED FROM CAP RYLA AND WILL BE SENT HOME AT MY PARENTS OR GUARDIANS EXPENSE.

24175 S.E. Hwy 450, P.O. Box 49, Umatilla, FL 32784 * 352-669-9443 or 1-800-523-1673

ROPES CHALLENGE COURSE
PARTICIPATION AGREEMENT - ASSUMPTION OF RISK

1. I (Please print participants full name) understand that the Florida Elks Youth Camp's Ropes Challeng Course is an oudoor adventure activity and that certain known and unknown inherent risks may exist in relation to this unique activity.
2. I understand that some, but not all, of the risks may include:

extreme temperature or weather conditions	bruises and/or scrapes to body
risk of falling and/or equipment failure	bee stings or insect bites
emotional distress	heat-exhaustion heat-stroke
serious injury	physically difficult conditions

3. I understand that the Florida Elks Youth Camp operates all programs on a Challenge by Choice basis. I understand that i am free to choose NOT to participate in any activity of PART OF any activity that i do not want to participate in.
4. I understand that the Florida Elks Youth Camp's Ropes Challenge Course staff will meet professionally accepted standards of care and safety. I understand that safety rules will be discussed throughout the day and it is my responsibility to ensure that I uderstand and follow all safety guidelines.
5. I understand that it is my responsibility to inform the Florida Elks Youth Camp staff of any and all physical limitaions, liabilities, or inuries including but not limited to: neck and back problems, recent surgery, allergies and any other medical situations.
6. I understand that the Florida Elks Youth Camp, its staff, employees, independent contractors and associates shall not be held liable or responsible in any way to me for bodily injury, illness (whether mental or physical), property damage or loss. The terms hereof shall serve as a release and assumption of risk for myself and all members of my family. Should the Florida Elks Youth Camp, or anyone acting on its behalf, be required to incur attorney's fees to enforce this agreement. I agree to indemnify and reimbures them for such fees and costs.
7. Specifically exempted from this release are any injuries caused by the gross negligence of any Florida Elks Youth Camp staff as it specifically relates to the Ropes Challenge Course safety procedures.

8. I HAVE READ UNDERSTOOD AND ACCEPTED THE CONDITIONS STATED HEREIN AND HEREBY ACCEPT THE CHALLENGE OF THE FLORIDA ELKS YOUTH CAMP ROPES CHALLENGE COURSE PROGRAM.

FLORIDA ELKS YOUTH CAMP, INC.
INFORMED CONSENT/MEDICAL INFORMATION

Group Name:  Course Date:

Participat's Name: DOB: Address: City: State: Zip: Home Phone:  SSN#:
Name of Personal Physician: Phone:
Emergency Contact: Phone:
Do you have health/acciden insurance? (please click one)  yes no
If yes, please list carrier and policy number:
Do you have any limiting physical health disabilities? (please click one)  yes no
If yes, please explain:
Are you taking any medication, prescribed or otherwise? (please click one)  yes no
If yes, list medicatioin and condition for which medicine is takes.
List any and all known allergies. (ie: medicine, insects, etc.)
If allergic to bee stings/ant bites, do you carry a sting/bite kit? (please click one)  yes no
Please click Yes or No to the followings questions:
Can you swim?  yes no
Are you pregnant?  yes no
Do your wear contact lenses?  yes no
Under the influence of any chemical substance including alcohol?  yes no
Do you currently have of have had in the past any of the following symptoms or conditions? (please click each that apply)

If you marked YES to any of the above, please explain each item & give dates:



List any other conditions(s) we should be aware of:

I understand the above information and a release to treat, in the event of an emergency. I and my family release FEYC, its employess, staff and other agents from any claims or liability arising out of my participation in the Florida Elks Youth Camp Ropes Challenge Course.

Participants Signature: Date:

** Parents/Guardians Signature if participant is under 18:

** Printed Name of Parents/Guardians: Emergency Phone #:

Camp RYLA

Student Name:  Nickname:
Student Phone Number:
Student Email:
Name of School:
Grade:
Please Indicate T-Shirt Size (please click one):

XSSMLXL2XL3XL

Please Indicate Dietary Restriction:
Vegan
Vegatarian
Gluten Free
Other
None

Camp RYLA

Parent / Guardian Informed Consent

PARENTAL AUTHORIZATION: I do voluntarily consent to said minor's participation in all activities of the Rotary Youth Leadership Awards. Camp RYLA to be held at the Elks Youth Camp, Umatilla, FL Dec 6- 10, . I assume responsibility for any medical or treatment fees or costs incurred directly or indirectly because of said minor's participation. I also authorize the representative(s) of Rotary District 6930 to arrange for professional care and treatment in case of a medical emergency. i hereby give my permission to the medical team selected by the Rotarian(s) to hospitalize, secure professional treatment for and/or order injections, anesthesia, and/or surgery for the minor name above.

RELEASE, ASSUMPTIONS of RISK and AGREEMENT TO HOLD HARMLESS
In consideration of the sponsoring Rotary Club, Rotary International District 6930, Rotary International, i permit my child to participate in the RYLA Leadership Camp and to engage in all said activities related to the camp's activities. I hereby assume the risk associated with participation and agree to hold the Florida Elks Youth Camp Inc., my representatives, and volunteers harmless from any and all liabilities, actions, causes of action, claims or demand of related to the RYLA camp. The terms here shall sever as a Release and the assumption of the risk for my child, his or her heirs, estate, executor, administrator, and assignees as well as members of my family.
I grant Rotary District 6930 and the sponsoring Rotary Club permission to use the image of the above named minor for educational and promotional purposes. In addition, Rotary District 6930 may contact the named minor regarding other rotary programs including, but not limited to, interact, Rotaract, speech contest, musical performance contest, and scholarship opportunities.