2015 NEW CAMP LOCATION: Clements Scout Ranch Athens, Texas Facilitator Training - January 23-25, 2015 Camp Session I - February 6 8, 2015 Camp Session II - February 20 22, 2015
INDEX I. Club RYLA Coordinator Packet p3. Contact Information p4. Camp Assignments By Club p5. General Information p6. Categories of RYLA Participants p8. Time Table p10. Questions and Answers p12. Areas of Responsibility p13. Recruitment Process p14. Sample Interview Questions p15. Guideline for RYLA Rotary Programs Following Camp p16. Letter to High School Counselors II. Student Information Packet p18. General Camper Information p19. Camper Application p20. Medical Release Form p22. Map Page 2 of 22
CONTACT INFORMATION Camp Chairperson Jeff Miller 719 W. Front St. #43 Tyler, TX 75702 pinevideo@mail.com CELL: 903 245 6202 OFFICE: (903) 526-0608 Camp Registrar Dave Eisele 945 Wilburn Paris, TX 75460 dte@parisorthopedic.com CELL: 214-608-8111 OFFICE: 903-737-0018 RYLA Board Members Ridley Briggs Mt Vernon Jeff Miller Tyler Shawn Reeves - Paris Dave Eisele Paris Robby Russell - Paris Andi Darby Texarkana Mel Morgan Tyler Karen Maines Longview Tommy Warren Longview Mason Crenshaw - Paris Rachel Trimble Idabel, OK Director for RYLA Club Coordinators Ridley Briggs 379 Trappers Trail Mt Vernon, TX rbriggs@peoplescom.net HOME: 903-860-2555 For EMERGENCIES ONLY during camp sessions: Clements Scout Ranch 11217 FM 2970 Athens, TX 75751 PHONE: (903) 675-3781 (903) 675-0293 Page 3 of 22
CAMP ASSIGNMENTS by CLUB (Geographical Location) District 5830 RYLA will hold two camp sessions. Campers for each session will be assigned their Session according to the geographical location of the sponsoring club as follows: Session 1 (Southern Clubs) 1. Athens 2. Bullard 3. Canton 4. Carthage 5. Cedar Creek Lake 6. Henderson 7. Jacksonville 8. Kilgore 9. Lake Fork 10. Lindale 11. Longview 12. Longview - South 13. Longview - Greggton 14. Malakoff 15. Marshall 16. Marshall - Metro 17. Overton 18. South Tyler 19. Troup 20. Tyler Sunrise 21. Tyler Downtown 22. Wills Point Session 2 (Northern Clubs) 1. Atlanta 2. Big Sandy 3. Clarksville 4. Gilmer 5. Gladewater 6. Hawkins-Holly Lake 7. Hugo, OK 8. Idabel, OK 9. Jefferson 10. Mineola 11. Mt. Pleasant 12. Mt. Vernon 13. Paris - Greater Paris 14. Paris 15. Pittsburg 16. Quitman 17. Sulphur Springs 18. Texarkana International 19. Texarkana - Oaklawn 20. Texarkana - Sunrise 21. Texarkana - Wilbur Smith 22. West Bowie County 23. Winnsboro Page 4 of 22
GENERAL INFORMATION THE DATES Session #1-3:00 p.m., February 6, 2014 thru 5:30 p.m. February 8, 2014. Session #2-3:00 p.m., February 20, 2014 thru 5:30 p.m. February 22, 2014. THE COST $400.00 for two Campers ($200 each) one male and one female from each high school that your club represents. Each additional student is also $200. A $25 DISCOUNT per camper is available if the money is submitted by NOVEMBER 1 st! THE PLACE Clements Scout Ranch / Trevor Rees-Jones Scout Camp 11217 FM 2970 Athens, TX 75751 THE CANDIDATE Your best all-around high-school juniors with proven or potential leadership abilities. Each Rotary Club participating in the RYLA program will select at least one high school junior male and high school junior female to represent their club. THE PURPOSE To provide outstanding student leaders an opportunity to expand and develop their leadership skills at a weekend scholarship camp. THE OBJECTIVE To provide an atmosphere where future leaders will experience learning situations that will aid them in developing sound values. To promote an environment that will provide each individual with a basis of insight and understanding for intelligent leadership. To promote involvement that encourages the participants to think through appropriate actions based on values and ethics. To encourage students through cooperative activities and group dynamics to develop leadership skills that can be carried back to their individual high schools and modeled. Page 5 of 22
THREE CATEGORIES OF RYLA PARTICIPANTS 1. ADULTS a. Team Leaders Have final authority over and responsibility for the team s successful RYLA experience, which includes the training of new Team Leaders. Be thoroughly knowledgeable of the RYLA procedure of leadership training, including goals and methodology. Be familiar with team members, including background, talents, goals, and aspirations. Become cognizant of any weaknesses among individual campers, which the group may play a part in strengthening. Realize that the safety of every team member is your responsibility. Know where every team member is located at all times. Be present with your team at all times, except during sleep. Be knowledgeable of camp rules and regulations and be prepared to bring any violations to Camp Coordinator immediately. b. Other Adult Team Members At the Team Leader s direction, assist him/her in any way which will strengthen RYLA s leadership training program. Because it is anticipated that most Adults will become a Team Leader at some point in the future, it is critical that all Adults become totally familiar with the Team Leader s responsibilities. 2. SENIORS a. Attendees from last year s camp, who have been asked to return to help in making this year s camp a success. Must draw a line between facilitator/camper although age difference is only one year and camper experience only one year back. Must realize that, as a facilitator, your primary responsibility is to aid the Team Leader in any way he/she directs in order to accomplish the team s goals. Past experience indicates that Seniors have a tendency to help campers rather than allow them to experience each event themselves. Seniors must learn (as all of us) that learning comes from experiencing..... not from detailed instruction. Report any rules violations to Team Leaders or to Camp Coordinator immediately. Page 6 of 22
3. CAMPERS a. An even number of male and female high school juniors, who have demonstrated leadership abilities to their school counselors, who have, in turn, recommended them to one of 45 Rotary clubs in District 5830. Each of those clubs have chosen campers from that list of recommendations and have agreed to pay the $200 fee for each camper and to furnish their transportation to and from the camp. No campers will be permitted to arrive at the camp late nor leave early. Campers will be expected to participate in all events, as well as to arrive at each event on time. Campers will be expected to present a program on their experiences at RYLA to their local Rotary Club subsequent to the close of camp. Page 7 of 22
ROTARY YOUTH LEADERSHIP AWARDS TIME TABLE JULY: Club president selects local Club RYLA Coordinator and informs the District s Coordinator Seminar Chairperson of selection. Schedule RYLA program for late February or early March at your local Club. SEPTEMBER: Attend the local Club Coordinators training at Camp Pirtle. Organize local club s RYLA Committee for student recruitment. Make appointments to talk with area high school counselors about the RYLA program and the type of students for which you are looking. Insert local Club RYLA Coordinator s name and phone number on the counselor cover letter and the camper applications and check session date. Distribute information to counselors at high schools. NOVEMBER: Deadline for submitting the Student Application to the School Counselor or local Rotary Club is November 15th. Deadline for submitting the number of students that your club wants to sponsor and the money for those students is due November 15th. Local Club RYLA Coordinator needs to contact the counselor and emphasize the deadline for receiving applications. Being able to send more than two students is on a first-come/first-served basis and no student applications will be processed without prepayment from the sponsoring club. Interview applicants for RYLA scholarships and make your primary and alternate selections. DECEMBER: If not already completed, Interview applicants for RYLA scholarships and make your primary and alternate selections. Notify each applicant and the school counselor of the committee s decision. Applications are due to District RYLA Registrar no later than December 15th. NOTE: Applications received after the deadline will be considered late and will be placed on the alternate list. FEBRUARY: Obtain volunteers from your club to provide transportation for your RYLA campers to the camp and to pick them up and return them to their homes when the camp concludes. Page 8 of 22
Provide each of the students selected by your committee a copy of the enclosed packet of information on RYLA camp. Schedule your RYLA campers to attend one of your club meetings as a program. Follow up with the students and make sure all forms have been turned in to the district RYLA coordinator. Ensure that each student has their signed medical release/informed consent form and that they bring it with them to camp. Inform the students parents by telephone who will be taking their child to the camp, when they will return and answer any questions the parents might have. If there are any changes to plans for picking students up from camp after the weekend starts, use the contact numbers provided so we may notify the students. Invite your RYLA participants back to your club to make a presentation on their RYLA experience IMMEDIATELY FOLLOWING CAMP. THIS IS VERY IMPORTANT! Page 9 of 22
QUESTIONS AND ANSWERS What is Rotary International? Rotary International is an international service organization that is over 100 years old. It is organized into local clubs in more than 150 countries, which work to fulfill the goals and objectives of Rotary International. Membership in local clubs is comprised of men and women from various occupations and professions. Rotary has a strong emphasis on promoting high ethical standards among its members and working across the globe for world understanding and peace. The RYLA program is a key element of Rotary s program and is designed to equip outstanding young people to become effective future leaders. Where did the RYLA program originate? RYLA began in Australia in the 1960s as a program to identify and develop those young people with leadership skills. These young people become very positive influences and role models once they return to their schools. Our district held its first camp in 1996 and has influenced the lives of approximately 1000 young people in our district in that time. Who is chosen to attend a RYLA camp? Each Rotary Club in District 5830 has the opportunity to award scholarships to the camp. Applicants are recommended by their high school counselors, teachers and principals on the basis of service work performed, leadership ability, academic performance and citizenship. To be eligible, students must be high-school juniors. Representatives of their local Rotary Clubs will interview applicants and then make the selections. The scholarships that are awarded cover all expenses of attending Camp RYLA. The local Rotary Club will provide round-trip transportation to Clements Scout Ranch. Over 180 scholarship winners will attend this year s RYLA sessions. What do the students actually do at a RYLA camp? Students will arrive at Clements Scout Ranch on Friday afternoon. The camp will conclude on Sunday afternoon. The curriculum is comprised of small focus groups that tackle various problems and work together for solutions. Group dynamics, counseling, leadership styles and risk taking are all subjects which are discussed and taught. Also, the curriculum has a strong emphasis on challenging physical obstacles, which must be overcome on the outdoor obstacle course. So the RYLA adventure has both indoor and outdoor components and is both mentally and physically challenging. It is an experience the student will never forget. Page 10 of 22
Who are the instructors at a RYLA Camp? All of the instructors are very experienced in working with young people. Many of them come from college settings and from the business world. Select Rotarians and distinguished visitors provide the students with excellent role models and information resources. Exactly where will this year s RYLA Camp be held? District 5830 of Rotary International has arranged to use the outstanding facilities at the Clements Scout Ranch / Trevor Rees-Jones Scout Camp just south of Athens, Texas. Students will be housed in heavy duty tents situated on wooden platforms. There will be a cot for each camper to sleep on. They will utilize the food service facilities of the camp. What about medical emergencies at Clements Scout Ranch? The staff at Clements Scout Ranch is experienced in handling the medical needs of its visitors. Each student s physical safety is a top priority and necessary medical assistance is readily available. All students will be covered by supplemental insurance provided by the Boy Scouts of America. Why would a high school junior want to attend a RYLA camp? First, only the most outstanding high-school juniors from the region will be invited to attend. Therefore, students will associate with the best students area schools have to offer and competition for the slots will be keen. Second, attendance at leadership camps such as RYLA will be of benefit to students when they prepare their college admission applications. College admission officials are impressed with students who are selected for and attend camps such as RYLA. Third, RYLA graduates will be more confident and self-assured in a variety of decision-making and leadership situations they will confront later in life. How will the students travel to the RYLA Camp site? Representatives of the Rotary Club that select the campers will provide transportation to and from Clements Scout Ranch. What if I still have more questions? Who can we speak with to get more information? See the CONTACTS on page 3 of the packet. Does RYLA District 5830 have a Web Site? http://www.ryla5830.org Page 11 of 22
AREAS OF RESPONSIBILITY CLUB PRESIDENT Select local RYLA coordinator for your club and notify district coordinator of your selection. Approve funds for RYLA campers. ($200 per camper) Periodically check with local RYLA coordinator to make sure timetable is on track. LOCAL CLUB RYLA COORDINATOR Become knowledgeable about RYLA program. Attend the special coordinator s training day at Clements Scout Ranch. Organize your club s camper selection committee. Know the timetable and all deadlines and make sure they are met. Schedule a RYLA program at your local Club as soon as the campers return! Make sure that all selected applicants attend the camp. Make sure the RYLA candidates and alternates are informed of all elements of the program. Arrange for each student s transportation to and from the camp by a club member. This is a good opportunity for the candidate to find out more about Rotary and for your club to learn more about RYLA on the return trip. The campers are not allowed to take their own vehicles to camp. If one of your club s prior year RYLA campers has been selected to return as a camp counselor, include them in your selection committee and transportation plans. HIGH SCHOOL COUNSELOR Help identify a pool of eligible students, both young men and young women, from which to select the best candidates. A realistic club goal would be eight to ten interviews. The counselor is not to select the camper, as that is the role of the club s camper selection committee. Distribute brochures and camp applications throughout the high school early in the school year to encourage student interest. Page 12 of 22
THE RECRUITMENT PROCESS RECRUITING Review your club s copy of the RYLA video to become familiar with the RYLA program. Talk with your high school counselors early in the process to inform them about the RYLA program. In early October distribute copies of the RYLA application with the counselor cover letter. Make sure that the high school counselors understand they are an important link in the selection process. Express to the high school counselors the far-reaching benefits their high school will receive by sending quality leaders. These scholarship winners will bring back information and new skills that will benefit many others in the student body of their high school. Some of the things that should be considered are: Service work performed (school, church, and community) Involvement in school activities including athletics Work experience Significant personal achievements Additional high school leadership roles Overweight and physically challenged individuals will have greater difficulty handling the physical challenges of Camp RYLA. If you have more than one club in your area, coordinate your efforts at the local high school, or if you have more than one high school, make sure that you develop candidates at all schools. Also, don t overlook private schools or home-schooled students in your community. INTERVIEWING Organize a club interview committee. Arrange an interview time for all the candidates from each school. Ask the same interview questions to each candidate. Be sure to select an alternate for each scholarship winner. ORIENTATION Be sure that your candidates are aware that they are receiving an award. The scholarship they receive to attend RYLA camp is the Rotary Youth Leadership Award. Make them aware of the commitment that your club has made and that they will make in attending. Inform them that they are to attend the full weekend, regardless of unforeseen school, church or family activities (3:00 p.m. Friday to 5:30 p.m. Sunday). If they cannot commit to this requirement, please select another candidate. Notify each candidate as to the results of your committee s selection. Follow up with the selected students and their parents to ensure that all questions regarding camp are answered. Give them a copy of the student information in this packet. Send the original applications to the district RYLA coordinator by the deadline. Retain a copy for your records. Page 13 of 22
SAMPLE INTERVIEW QUESTIONS These questions are provided to help you (Rotarians charged with interviewing high school juniors to be selected as attendees for RYLA camp) stimulate responses from the students that will enable you to select to best candidates. In addition to the questions below you may use other questions you feel are appropriate to each interview to get the best results. Be sure to ask each applicant the same questions during interviews. You will not have time to ask many questions, so pick those questions that apply best to your club s area. 1. If I were to call your parents or teachers, what would they tell me are your two greatest strengths? Your two greatest weaknesses? 2. Who had the most influence on your life and how? 3. When you accomplish a task, how do you determine if you have done a good job? 4. What traits of a good leader do you admire most? 5. If you were interviewing candidates for this award, what leadership qualities would you look for? 6. Can a high school junior be an influential leader? If so, how? 7. What is the number one leadership quality you look for in a school leader? In a national leader? 8. Other than a family member, who is/are your hero/heroes? And why? 9. Name the best leader you have ever heard of. Why? 10. Is there anything you would like to share with us that would give us a reason to select you for RYLA camp instead of another student? 11. What five things do you value most in life? 12. If you had only six months to live how, would you spend your time? 13. If you suddenly came into a large amount of money, how do you think it would change your life? 14. What kinds of experiences in life give you the greatest feelings of importance? 15. If you knew you could not fail, what one great thing would you dare to dream? 16. Do you have any questions about RYLA camp you would like to ask? Page 14 of 22
GUIDELINES FOR CAMPERS TO SPEAK AT ROTARY MEETINGS FOLLOWING THEIR CAMP 1. Students (and counselors if present) are introduced. 2. Student explain their RYLA Name and how they decided on it 3. Students should express their appreciation to Club members for sponsoring them. 4. 1 or 2 students speak about Friday s experience. 5. 1 or 2 students speak about Saturday s experience. 6. 1 or 2 students speak about Sunday s experience. 7. Students should express specifically 1. How RYLA changed the way they perceive leadership? 2. What it takes to be an effective leader in today s society? 3. How will it change their life in school, church, and their community? Page 15 of 22
Dear High School Counselor, Rotary International District 5830 will host select high-school juniors in a weekend leadership development program called RYLA (Rotary Youth Leadership Award) camp. The purpose of RYLA camp is to provide outstanding high-school juniors who exhibit outstanding leadership qualities in their high-school activities, an opportunity to develop those skills in a team working and bonding environment designed to challenge them to excel. Rotary District 5830, through its local Rotary clubs, will award all-expense-paid scholarships to high-school juniors from your school. We will award approximately 180 scholarships in District 5830 and our challenge is to select the very best student leaders we can. That is why your involvement is so important. For the selection process, we would like to interview at least eight to ten students for the scholarships to be awarded in your school. Since Camp RYLA is co-educational we must select both young men and young women. Your influence and assistance in getting the applications into the hands of the best candidates will be greatly appreciated. The benefit to you and to your school comes with the opportunity to provide recognition for students who exhibit service and leadership achievement and are wellrounded individuals. In addition, you have the assurance that all students will be positively influenced by the example and leadership that your RYLA participants provide when they return to their positions within your school. You will notice the difference and you will be proud of them. Camp RYLA will be held at the Clements Scout Ranch near Athens, Texas. Attached to this letter are several copies of the scholarship application which you may distribute to those students you feel would make good applicants. Completed applications may be returned to the local Rotary Club s RYLA coordinator whose name is shown below. The deadline for submitting all applications to your local sponsoring Rotary Club is November 15th. The RYLA Coordinator representing the Rotary Club in your area is: Local Club RYLA Coordinator: Phone #: The Camp Session designated for campers from this school is (check only one): Session 1: February, 6-8, 2015: Session 2: February 20-22, 2015: Page 16 of 22
STUDENT INFORMATION PACKET (To be given to all chosen primary and alternate candidates) The following pages contain: 1) GENERAL INFORMATION 2) RYLA STUDENT APPLICATION To be turned in to School Counselor 3) MEDICAL RELEASE/INFORMED CONSENT FORM MUST be brought to Camp SIGNED BY PARENT 4) MAP TO CLEMENTS SCOUT RANCH Note: These forms can also be downloaded from the District 5830 RYLA Website (http://www.ryla5830.org) Page 17 of 22
HOW ARE MEDICAL EMERGENCIES HANDLED AT THE CAMP? The staff at Clements Scout Ranch is experienced in handling the medical needs of its visitors. Each student s physical safety is a top priority and necessary medical assistance is readily available. All students will be covered by supplemental insurance provided by the Boy Scouts of America. Please fill out the enclosed medical release/informed consent form and bring it with you to the camp. HOW WILL I TRAVEL TO CAMP RYLA NEAR ATHENS, TX? A representative of the Rotary Club that selected you will provide transportation to and from the camp. Registration starts at 3:00 p.m. on the Friday of your camp session. The camp concludes at 5:30 p.m. on the Sunday of your camp session. If for any reason you cannot make it to the camp by the starting time, please contact your club sponsor or the RYLA Registrar so that another student can be selected. WHERE WILL I SLEEP? Your sleeping accommodations will be in modern cabins. You will have a clean bed or cot, but you will need to bring a sleeping bag and pillow. There will be heaters, but be prepare for possible cold sleeping conditions. WHAT ABOUT THE FOOD? It will be professionally prepared, tasty and nutritious. Because of the long, strenuous days you have three square meals. If you have special dietary restrictions, please let us know as soon at least 2 weeks prior to camp. ARE THERE ITEMS I SHOULD OR SHOULDN T BRING? Items you should bring (marked with your name) include: Warm clothes including two or three pairs of jeans, and lighter clothes for mild weather Extra socks! Warm coat, as well as a lighter windbreaker-type jacket Cap or hat Two pairs of shoes or boots (tennis shoes you don t mind getting dirty) Leather gloves or leather-palmed gloves Personal care items including lip balm, soap, towels and washcloths Sleeping bag and pillow Flashlight MEDICAL RELEASE FORM Items that I should NOT bring to camp: Electronic items (including cell phones or pagers) Jewelry (it can be very hazardous during the activities) Alcohol Tobacco products Knives, firearms or any kind of weapon Page 18 of 22
Rotary Youth Leadership Award District 5830 RYLA Camper Application (Please Print Clearly) High School: Male Female Name: Address: Home Phone: LAST FIRST PREFERRED NAME STREET CITY STATE ZIP Date of Birth: Cell Phone: Shirt Size: XS S M L XL XXL Parents (Cell) Phone: GPA: EMAIL ADDRESS: (This Email address will be listed on the camp roster and distributed to all campers for future communications) (You May Attach a Resume or Information on Separate Sheet) SCHOOL and EXTRA CURRICULAR ACTIVITIES (Including Sports) : ACADEMIC ACCOMPLISHMENTS (Awards / Honor Roll / Advance Classes / GPA) : OUTSIDE OF SCHOOL ACTIVITIES, INTERESTS, HOBBIES: The RYLA (Rotary Youth Leadership Award) program is for a select group of high school juniors who have shown strong leadership skills. Students will spend two nights at WORK EXPERIENCE: 1) Information below Rotary Club: 2) APPLICATION MUST BE SIGNED AND HAVE CURRENT PHOTOGRAPH ATTACHED! APPLICATION MUST BE SUBMITTED TO YOUR SCHOOL COUNSELOR OR ROTARY REPRESENTATIVE BY MUST DATE to be filled out by the sponsoring Rotary Club. Club Coordinator: Home Phone: Work Phone: Cell Phone: NOVEMBER 15th! The RYLA (Rotary Youth Leadership Award) program is for a select group of high school juniors who have shown strong leadership skills. Students will spend two nights at Clements Scout Ranch near Athens, TX and participate in the COPE (Challenging Outdoor Personal Experience) ropes course. By signing below I acknowledge that I have read the attached information sheet and approve the application. I also understand that use of facilities owned by the Circle Ten Council, BSA, involves a certain degree of risk that could result in injury or death. I hereby release and waive any and all claims that I may have against the Circle Ten Council, BSA and their employees, agents, representatives, or volunteers arising from use of their facilities. I agree to allow the camp nurse, doctor, or designated medical personnel to dispense any non-prescription medication to my child if necessary. In case of a medical emergency I understand every possible effort will be made to contact me, although in the event I cannot be reached I hereby give my permission to the healthcare provider selected by the Camp Director to hospitalize, secure proper treatment, order an injection, anesthesia, or surgery for my child whose name is listed above. Parent Signature Print Name Decision for Participation: Applicant Signature Male Female PRIMARY CHOICE 1 st ALTERNATE 2 nd ALTERNATE DATE
Last name: DOB: Allergies: Emergency contact No.: Annual Learning for Life Health and Medical Record Part A GENERAL INFORMATION Name Date of birth Age Male Address Grade completed (youth only) City State Zip Phone No. Adult leader Council name/no. Post No. Social Security No. (optional; may be required by medical facilities for treatment) Religious preference Health/accident insurance company Policy No. In case of emergency, notify: ATTACH A PHOTOCOPY OF BOTH SIDES OF INSURANCE CARD (see Part C). IF FAMILY HAS NO MEDICAL INSURANCE, STATE NONE. Name Relationship Address Home phone Business phone Cell phone Alternate contact Alternate s phone MEDICAL HISTORY Are you now, or have you ever been treated for any of the following: Allergies or Reaction to: Female Yes No Condition Explain Medication Asthma Diabetes Hypertension (high blood pressure) Heart disease (i.e., CHF, CAD, MI) Stroke/TIA COPD Ear/sinus problems Muscular/skeletal condition Menstrual problems (women only) Psychiatric/psychological and emotional difficulties Learning disorders (i.e., ADHD, ADD) Bleeding disorders Fainting spells Thyroid disease Kidney disease Sickle cell disease Seizures Sleep disorders (i.e., sleep apnea) GI problems (i.e., abdominal, digestive) Surgery Serious injury Other Food, Plants, or Insect Bites Immunizations: The following are recommended by Learning for Life. Tetanus immunization must have been received within the last 10 years. If had disease, put D and the year. If immunized, check the box and the year received. Yes No Date Tetanus Pertussis Diptheria Measles Mumps Rubella Polio Chicken pox Hepatitis A Hepatitis B Influenza Other Exemption to immunizations claimed. MEDICATIONS List all medications currently used. (If additional space is needed, please photocopy this part of the health form.) Inhalers and EpiPen information must be included, even if they are for occasional or emergency use only. Medication Strength Frequency Reason for medication Approximate date started Temporary Permanent Medication Strength Frequency Reason for medication Approximate date started Temporary Permanent Medication Strength Frequency Reason for medication Approximate date started Temporary Permanent Medication Strength Frequency Reason for medication Approximate date started Temporary Permanent (For more information about immunizations, as well as the immunization exemption form, see Learning for Life s Safety First Guidelines.) Medication Strength Frequency Reason for medication Approximate date started Temporary Permanent Medication Strength Frequency Reason for medication Approximate date started Temporary Permanent NOTE: Be sure to bring medications in the appropriate containers, and make sure that they are NOT expired, including inhalers and EpiPens. You SHOULD NOT STOP taking any maintenance medication.
Part C Informed Consent and Hold Harmless/Release Agreement I understand that participation in Learning for Life activities involves a certain degree of risk. I have carefully considered the risk involved and have given consent for myself and/or my child to participate in these activities. I understand that participation in these activities is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. I release Learning for Life, the local council, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with the activity from any and all claims or liability arising out of this participation. I approve the sharing of the information on this form with Learning for Life volunteers and professionals who need to know of medical situations that might require special consideration for the safe conducting of Learning for Life activities. In case of an emergency involving me or my child, I understand that every effort will be made to contact the individual listed as the emergency contact person. In the event that this person cannot be reached, permission is hereby given to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for me or my child. Medical providers are authorized to disclose to the adult in charge examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant s parents or guardian, and/or determination of the participant s ability to continue in the program activities. Without restrictions. With special considerations or restrictions (list) Talent Release Form I hereby assign and grant to Learning for Life the right and permission to use and publish the photographs/film/videotapes/electronic representations and/or sound recordings made of me or my child by Learning for Life, and I hereby release the Learning for Life from any and all liability from such use and publication. I hereby authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution of said photographs/ film/videotapes/electronic representations and/or sound recordings without limitation at the discretion of Learning for Life, and I specifically waive any right to any compensation I may have for any of the foregoing. Yes No I understand that, if any information I/we have provided is found to be inaccurate, it may limit and/or eliminate the opportunity for participation in any event or activity. Participant s name Participant s signature Parent/guardian s signature (if under the age of 18) Date Attach copy of insurance card (front and back) here. If required by your state, use the space provided here for notarization. 1329 W. Walnut Hill Lane P.O. Box 152225 Irving, TX 75015-2225 www.learningforlife.org 680-001 2009 Learning for Life Part C Last name: DOB:
MAP Camp RYLA is held at the Clement Scout Ranch near Athens, Texas 11217 FM 2970 Athens, TX 75751 PHONE: (903) 675-3781 (903) 675-0293