Student Application

Download Release Agreement

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Student Information

Name*

First Last

Nickname

Gender*

Pronoun Preference

Email*

Phone*

May we send texts to this number, if needed?*

Yes

Address*

Street Address Address Line 2 City State ZIP Code

T-Shirt Size*

School District*

High School*

Rotary Club Sponsoring Information

Name of Rotary Club Sponsoring You*

What city is your school in?*

Please supply this if you do not know what club is sponsoring you

Your Rotary Contact's Name

First Last

If known

Phone

If known

Do you have any dietary needs or food allergies that would be helpful for staff to know or may require accommodation?

Do you have any medical needs that would be helpful for staff to know or may require accommodation?

All medical and medication information will be kept confidential.

Camp RYLA strives to be an inclusive experience. Please let us know if there is anything in particular that will make the camp experience supportive of your needs. Some items to consider that we can provide options for with advance notice.

For instance, the cabins and restrooms at Camp St Croix built to be divided by gender; there is no formal dedicated time in the schedule for religious observances; and some areas of the property are harder to navigate for all abilities.

Would you like to discuss any of the above with a member of camp staff prior to the camp including discussions of housing, meals or other matters where you might want/need special accommodations?

Yes, Please contact me

RELEASE, INDEMNIFICATION AND HOLD HARMLESS AGREEMENT
In consideration of participating in Camp RYLA activities, and for good and valuable consideration, I hereby agree to release and discharge any liability which may arise from such participation (1) the YMCA Greater Twin Cities; and (2) the Rotary Clubs of Rotary Districts 5960 and 5950, along with the owners, directors, officers, employees, agents, members, volunteers, participants and all other persons or entities acting for or on behalf of either organization (hereinafter collectively referred to as “Releasees”), on behalf of myself, my parents, siblings, heirs, assigns, personal representative and estate, and also agree as follows:

I acknowledge that participating in RYLA/YMCA activities involves known and unanticipated risks which could result in physical or emotional injury, paralysis or permanent disability, death, and property damage. Risks include, but are not limited to, broken bones, torn ligaments or other injuries as a result of falls or contact with other participants; death as a result of drowning or brain damage caused by near drowning in pools or other bodies of water, medical conditions resulting from physical activity, and damaged clothing or other property. I understand such risks simply cannot be eliminated, despite the use of safety equipment, without jeopardizing the essential qualities of the activity.
I expressly accept and assume all of the risks inherent in this activity or that might have been caused by the actions of the Releasees. My participation in these activities is purely voluntary and we elect to participate despite the risks. In addition, if at any time I believe that event conditions are unsafe or that I am unable to participate due to physical or medical conditions, then I will immediately discontinue participation.
I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless Releasees from any and all claims, demands, or causes of action which are in any way connected with my participation in these activities, or my use of their equipment or facilities. This release does not apply to claims arising from negligence or intentional conduct. Should Releasees or anyone acting on their behalf be required to incur attorney’s fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.
I represent that I or my family have adequate insurance to cover any injury or damage I may suffer or cause while participating in this activity, or else I agree to bear the costs of such injury or damage myself. I further represent that I have no medical or physical conditions which could interfere with my safety in these activities, or else I am willing to assume – and bear the costs – all; risks that may be created, directly or indirectly, by any such condition.
In the event that I file a lawsuit, I agree to do so in the state where such injury incurred, and I further agree that the substantive law of that state shall apply.
I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.

Student Signature*

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Date*

Typed Name*

First Middle Initial Last

Student Information

Parent/Guardian Information

Rotary Club Sponsoring Information