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RYLA+ MEDICAL INFO AND CONSENT, PUBLICITY & LIABILITY RELEASE FORM

Medical Consent Statement

I consent to (Participant’s Name) (hereinafter “participant”) participating in RYLA+. I/we understand that these activities are part of what made the RYLA program so successful in the growth of young people and that my/our student has my/our approval to participate in all the activities during the program, except as noted. 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 5750, 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 below 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.

In the event of an emergency and medical attention is required for a student at RYLA+, the providing of the attention will not be construed as an admission of liability on the part of RYLA+ and cost for all emergency treatment, and care must be borne by the parents or guardians of the involved student. Should RYLA have voluntary insurance coverage to cover such expenses, such coverage will be limited to the excess over any valid and collectible insurance carried by the injured student’s parents or guardians.

In the case of a medical emergency, I understand that every effort will be made to contact parents or guardians of students. In the event that I cannot be reached, I hereby give permission to the physician selected by the RYLA Director to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child/ward as name herein. I understand that my child/ward will be asked not to attend RYLA if illness or emergency will preclude him/her from participating fully in all RYLA+ activities.

___________________________________________________

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?

Appendix Removed

Fainting Spells

Asthma

Heart Trouble

Convulsions

Diabetes

None of These

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:

___________________________________________________

RYLA+ Photograph, Publicity & Liability Release Form

I, (Signer's Name), give Rotary District 5750, its Rotary Clubs, and Leader N U LLC. permission to use the participants 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 or made during an online or in-person portion of RYLA+ on behalf of Rotary District 5750 and/or Leader N U, LLC. I agree that Rotary District 5750, 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 5750, 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.

In consideration for being permitted to participate in the Rotary Youth Leadership Awards (RYLA) and all associated RYLA+, Rotary District 5750, and Leader N U, LLC. activities:

I support my child’s/ward’s application to RYLA+, and I agree that if he/she is selected to attend RYLA+, he/she will
complete the entire program.
I, the undersigned parent or legal guardian,/we 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, LLC., Rotary International District 5750, 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+ Retreat 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+.
Student, for himself or herself, his or her spouse, parents, legal representatives, heirs, and assigns, hereby releases, waives and discharges RYLA, Rotary International, Rotary International District 5750, its officers and members, Leader N U, LLC., all promoters, sponsors, advertisers, owner and lessees of the premises upon which RYLA+ is conducted, and each of them and their officers and employees (referred to hereinafter as “Releasees”) from all liability to student, spouse, parents, legal representatives, heirs, and assigns for any and all loss or damage, and any claim or damages resulting therefrom, on account of injury to student’s person or property, even injury resulting in death of student, whether caused by negligence of Releasees or otherwise while student is participating in the RYLA+ activities.
Student agrees to indemnify Releasees and each of them for any loss, liability, damage, or cost they may incur due to the presence of student in or upon the RYLA+ premises or activities, whether caused by the negligence of Releasees or otherwise.
Student hereby assumes full responsibility for risk of bodily injury, death, or property damage due to the negligence of the Releasees or otherwise, while in or upon the RYLA+ premises or activities, and while competing, officiating in, working or for any purpose participating in the RYLA+ activities.
Student expressly agrees that this release, waiver, and indemnity agreement is intended to be as broad and inclusive as permitted by the laws of the State of Oklahoma; and that if any portion hereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in legal force and effect.

I give consent to Rotary District 5750, its Rotary Clubs, and Leader N U, LLC. to use the participant's 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+.

____________________________________

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:

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Your legal name

Your email address

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April 1, 2026 12:00 pm CDT

D5750 - RYLA+ Parent Forms Uploaded by Bridget Markwood - admin@leadernu.com IP 68.97.5.244