District 5390 Rotary Youth Leadership Academy
July 11-15, 2023
Standards of Conduct and Medical Release Form
To Be Completed by Selected RYLA Camper & Parent/Guardian:


I understand that the Rotary sponsored Youth Leadership Academy will be held at Luccock Park near Livingston, MT from
Saturday, July 11, 2023 to Wednesday, July 15, 2023. I agree to make myself available for those dates and to abide by the
standards of conduct described herein.
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Email *
Camper Name:
WOULD you like a pronoun listed on your name badge?
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What is your birth Gender?
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Mailing Address:
City,  State, Zip:
Date of Birth:
Phone Number:
Phone Number:
Signed:
Date:
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