Rotary Clubs only may COMPLETE THIS FORM BY May 1st

BEFORE submitting this form, please check with your Rotary Club to make certain that PAYMENT has been submitted! Completion of the information below along with your Club's payment will guarantee your student's participation at RYLA. Please let your student participants know that the District RYLA committee will be in contact with them sometime in May/June at which time they will be asked to complete an online registration form using a link sent to your Rotary Club's contact person.

Rotary Club of *

Rotarian Contact - First Name *

Rotarian Contact - Last Name *

Mobile Phone Number *

Other Phone Number

Email Address *

Participant # 1 Last Name: *

Participant # 1 First Name: *

Participant # 1 Telephone *

Participant #1 Email Address: *

Participant # 2 Last Name:

Participant # 2 First Name:

Participant # 2 Telephone

Participant # 2 Email Address:

Alternate # 1 Last Name:

Alternate # 1 First Name:

Alternate # 1 Telephone

Alternate # 1 Email Address:

Alternate # 2 Last Name:

Alternate # 2 Telephone

Alternate # 2 Email