ROTARY YOUTH LEADERSHIP AWARDS
ROTARY DISTRICT 7255
Facilitator Application
(PLEASE PRINT OR TYPE)
(COMPLETE BOTH SIDES)
Name: Name on name tag
Gender: Male Female Date of Birth:
Street Address:
Mailing Address: _
(If different from street address)
City: Zip:
Phone # Shirt Size: S M L XL XXL (CIRCLE ONE)
High School: Grade:
CELL PHONE #
My son/daughter has permission to attend the
RYLA event (DTBA) along with all training sessions that will be conducted. I understand that my
student, if selected will be asked to raise $300 to help defray the training and weekend costs.
During the event, I may be reached at (phone #) . If I cannot be
reached in the event of an emergency, the following person is authorized to act in my behalf.
Name: Phone #
Parent/Guardian Signature: X Date:
Parent’s email address X_
Please list all food allergies:
There will be physical activities during this event. Please list any physical restraints:
Your
confirmation
letter
and
any
RYLA
notices
will
come
to
you
via
e-mail,
please
print
your
whole
E-mail
address
below.
Remember to check your e-mail
.
E-mail:
PLEASE ANSWER THE FOLLOWING QUESTIONS AND BE SPECIFIC.
( use another piece of paper to TYPE your answers)
1. What event(s) have you participated in that has developed your leadership skills, other
than RYLA? Be specific about the event(s) and your role in that event(s).
2. What leadership positions have you held, in and out of school?
3. What is most significant about RYLA to you that make you want to return as a facilitator?
4. What do you think you can contribute to RYLA?
5. What is your definition of a good facilitator?
6. What was your favorite activity at RYLA and why?
Please complete this application including the questions and return to
the address below by September 1, 2017 Applicants will be notified of their
acceptance by e-mail in November.
Keep in mind that you must attend a training weekend and also raise $300 to help defray the
costs of the two weekends. The $300 will be due a month before the event. The dates have
not been confirmed at this time. At the time of notification of acceptance as a facilitator, you
will be informed of the dates of RYLA 2017 and the training.
ANY QUESTIONS REGARDING BEING AFACILITATOR SHOULD BE
DIRECTED TO: lyd_rich@hotmail.com
MAIL COMPLETED APPLICATIONS TO:
RYLA C/O Lydia Wells, 306 Johnson CT, Greenport, NY 11944
** STUDENTS WHO ATTENDED A ROTARY MEETING TO SHARE AND THANK THE
ROTARY CLUB FOR THE RYLA OPPORTUNITY WILL BE GIVEN PREFERENTIAL
TREAMENT. PLEASE HAVE THE CLUB PRESIDENT SIGN BELOW.
DATE VISITED SPONSORING ROTARY CLUB PRESIDENT’S SIGNATURE
PHOTO
RELEASE
FORM
I, being the Parent/Guardian of , hereby consent that his/her
name, image and likeness, as shown in the video-tapes, photographs and/or electronic images for
which he/she posed, and/or audio recordings made of his/her voice may be used by Rotary District
7255 for the promotion of RYLA (Rotary Youth Leadership Awards.)
Signature
of
Parent/Guardian
_
Date
IF YOU ATTENDED SUMMER RYLA , CHECK THE WEEK (S) YOU ATTENDED.
___WEEK 1 ___WEEK 2 ___BOTH WEEKS
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