D5320 - RYLA+ 2023 Medical & Publicity Release



Name of Sponsoring Rotary Club:
Participant's Full Name:
Sex: Grade: Age:
High School (if applicable):
Family Physician’s Name:
Phone #:
Name of Primary Insurance Policy:


Date of last Tetanus shot: 
Is the participant allergic to Tetanus Booster?

Has participant previously had appendix removed, fainting spells, asthma, heart trouble , convulsions, or diabetes?

Allergies to food or medicine? Specify:

Anything other to note (i.e. recent traumatic injury):

Has the participant ever had an anaphylactic reaction?
Is the participant required to carry an epinephrine auto injector?


Medical Authorization

Will medication be taken at camp? If yes, please fill out below: 

Activities to limit: 

Does Participant have any Existing Medical Conditions/Special Needs that need to be noted by staff: 


Medical Consent Statement

I consent to (Participant’s Name) (hereinafter “participant”) participating in RYLA. The participant has permission to engage in all prescribed activities, except as noted above. It is also understood that all rules and regulations for this event will be enforced and any violation by the participant will result in the participant needing to leave RYLA which could include a call to a parent/guardian to request pick-up of the participant. In consideration of participation in this event, I agree (or if participant is under 18, legal guardian agrees on behalf of the participant) to fully and forever release, discharge, indemnify and hold harmless Rotary District 5320, any sponsoring Rotary clubs, and Leader N U LLC., their agents, servants and employees, successors, insurers, assigns, and all other persons, firms or corporations who might be liable, from any and all claims, demands, damages, charges, costs rights or causes of action of whatever nature, present or future, whether the same be known, anticipated or unanticipated, resulting from or arising out of participation in this event. The participant (or legal guardian) also hereby authorizes any medical treatment required by the participant while in attendance at this event. Described above are any special medical or other needs required by the participant, and if necessary event personnel will be notified of any other special needs or information required.


RYLA+  Photograph, Publicity & Liability Release Form

I,  , give Rotary District 5320, its Rotary Clubs, and Leader N U LLC. permission to use my name, likeness, image, voice, and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images, zoom recordings and the like, taken during an online or in-person portion of RYLA+. I agree that Rotary District 5320, its Rotary Clubs, and Leader N U LLC. have complete ownership of such pictures, etc., including the entire copyright, and may use them for any purpose consistent with Rotary International Public Image guidelines. These uses include, but are not limited to illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, and any promotional or educational materials in any medium now known or later developed, including the Internet. I acknowledge that we will not receive any compensation, etc. for the use of such pictures, etc., and hereby release Rotary District 5320, its Rotary Clubs, and Leader N U LLC. and its agents and assigns from any and all claims which arise out of or are in any way connected with such use.

I, the undersigned parent or legal guardian, understand that participation in the the activities at RYLA involve some risk of personal injury, due to the nature of the activities offered. Students will be active during both the online and in-person portions of the retreat. All students are expected to follow the rules and instructions of the staff, which are in place to keep students safe. All staff are expected to do everything they can to keep students free from harm.

I, the undersigned parent or legal guardian, do hereby release Leader N U, Rotary International District 5320, their officials, officers, agents and employees from all claims, demands, damages, actions or causes of action, whether on account of damage to property, bodily injury or death, or from any negligence resulting from the camp, or from transporting my child to and from the various areas at which the RYLA Camp is held. The undersigned has carefully read the said release and executes same in consideration of the RYLA attendee being afforded the opportunity to attend RYLA 2023.

I have read and understood this publicity and liability consent and release.

to Rotary District 5320, its Rotary Clubs, and Leader N U, LLC. to use my name and likeness. I have also carefully read the said liability release and executes same in consideration of the RYLA attendee being afforded the opportunity to attend RYLA 2023.

Other person to notify in case of an emergency:
Emergency Contact Phone #:

(If Participant is under the age of 18, a parent or legal guardian will need to sign)
Signing Parent/Guardian Full Name:
Relationship to Participant:

Date Signed: 

Leave this empty:

Signature arrow sign here

Signature Certificate
Document name: D5320 - RYLA+ 2023 Medical & Publicity Release
lock iconUnique Document ID: 4be8edc1a1147fb87aeedc584447f8e125ec8940
Timestamp Audit
November 9, 2022 2:26 pm CSTD5320 - RYLA+ 2023 Medical & Publicity Release Uploaded by Bridget Markwood - admin@leadernu.com IP