First Name
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Last Name
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Name you wish to be called
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Address
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City
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State
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Zip
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Cell Phone #
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Email Address
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Date of Birth
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Gender
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Male
Female
T-Shirt Size
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Small
Medium
Large
X-Large
XX-Large
Color Headshot Photo for Program Book
Name of High School You Attend
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Will you participate in the Conference Band?
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Yes
No
If yes, What instrument(s) will you bring?
Will you participate in the Conference Choir?
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Yes
No
If yes, what will you sing?
Alto
Soprano
Tenor
Bass
Areas of Leadership (Hold down CTRL to make multiple selections)
National Honor Society
Student Council Officer
Class Officer
Interact Club
Editor in Chief of School Yearbook
Editor of School Newspaper
Captain or Co-Captain of any sports team
Officer of any Musical Group
Officer of any Club or School Organization
Peer/Counselor Tutor
Athletic Participation (Hold down CTRL to make multiple selections)
Baseball
Basketball
Field Hockey
Football
Golf
Lacrosse
Soccer
Swimming
Tennis
Track & Field
Volleyball
Wrestling
Other
Out of School Activities (Hold down CTRL to make multiple selections)
Scouting Leadership
Red Cross
Cancer Society
Food Pantry
Church/Synagogue/Mosque Youth Leader
Vacation Bible School
Teach in Church School
Children’s Center/Day Care
Camp Counselor
Recreational Role
4-H
Peer mentor/peer teacher
School Subjects: List those course in which you excel
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Hobbies or Areas of Special Interest
List Allergies or Special Medical Needs that would be relevant to the Conference:
Legal Guardian
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Legal Guardian: Phone #
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Legal Guardian: Email Address
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Legal Guardian:
Legal Guardian: Phone #
Legal Guardian: Email Address
In Case of Emergency, my child may be released to: Please list the names of 3 adults and provide their phone #s.
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Name of Sponsoring Rotary Club
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Carlisle
Carlisle-Sunrise
Colonial Park
D7390 Passport
Denver-Ephrata
Donegal Area
Eastern York County
Elizabethtown
Gettysburg
Hanover
Harrisburg
Harrisburg-Keystone
Hershey
Hummelstown
Lancaster
Lancaster-Hempfield
Lancaster Penn Square
Lancaster-Sunrise
Lancaster-South
Lebanon
Lititz
Littlestown
Manheim
Mechanicsburg-North
Millersburg
Mount Joy
Myerstown-ELCO
New Holland
Northern Lebanon County
Palmyra
Paradise
Perry County
Red Lion/Dallastown
Shippensburg
Southern York County
Susquehanna Township
Uptown York
West Shore
Yellow Breeches
York
York-East
York-North
By Completing this Application, I agree to attend the entire conference from start to finish. If I do not attend or leave early, I will be required to reimburse my sponsoring Rotary Club all or some of the $525 registration fee.
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I acknowledge that I have read and agree to this statement.
RYLA 2023 Waiver Form
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Security Code
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