Rotary Youth Leadership Awards

Register Your Details for RYLA 2012!

Step 1: Enter your details
Step 2: Complete your medical form
Step 3: We will process your application and contact you shortly

Mandatory fields are marked with an asterisk (*), but please supply at least 1 phone number and complete all fields if possible. If you don't know any Rotarians in the 9630 District and you are unable to obtain corporate sponsorship, please still complete the below form and every effort will be made to seek sponsorship for you to attend.
Sponsoring Club/Organisation:
Sponsor/Organisation Contact Name:
Sponsor/Organisation Contact Phone Number:
*Given Name:
*Surname:
Preferred Name: (if not your given name)
*Gender: Female     Male
*Date of Birth: Format dd/mm/yyyy
Mobile Phone:
Home Phone:
Work Phone:
*Email Address:
Postal Address:
Town/Suburb:
State:
Post Code:
Occupation/Course of Study:
Please indicate your preferred pick up time and location for Saturday morning 2nd July
You will need to arrive at your bus pick up point 30 minutes prior to departure:
  5:30 AM - Toowoomba Bus Interchange
  7:00 AM - Garden City, Mt Gravatt
  8:30 AM - Esk Bakery & Restaurant, 156 Ipswich St, Esk (main street)
I hereby make application for the 2012 Rotary Youth Leadership Award and
      understand that the award involves my attendance in a week long program.

RYLA 2012 - Saturday 30 June to Saturday 7 July