ALUMNI APPLICATION

Instructions for completing the application and interview process:

1. Fill out the required information fields below, and click the “Submit” button to email your pre-selection information to the RYLA Alumni Coordinator.
2. Print out the entire form, fill-in all additional information, and get all required signatures on the printed form.
3. Turn the entire completed Application form in to the alumni Coordinator whose name and address is listed at the end of the form.

Last Name: *

First Name: *

Name Tag: *

(What name would you like on your name tag?)

Home Address: *

City: *

State: *

Zip: *

Home Phone: *

Birth Date: *

E-mail Address: *

Gender: *

T-shirt size: *

School: *

Sweat Shirt Size: *

Sweat Pant SIze: *

RYLA Theme Suggestion: *

MEDICAL HISTORY OF APPLICANT: *

(All medical information must be disclosed and is kept strictly confidential by our professional medical staff members) Does applicant have any physical limitation or other condition or illness that is being treated that may require assistance while at camp?

If YES, describe:

Is applicant currently taking medication?: *

If YES, please list what medications are being taken:

If YES, please explain condition medication is being used/prescribed for:

Vegetarian: *

Other dietary restrictions:

Physician/Doctor name: *

Phone #: *

Health Insurance Carrier: *

Phone #: *

YOU MUST CLICK ON SUBMIT AND PRINT OUT THE FORM THAT FOLLOWS TO COMPLETE YOUR APPLICATION PROCESS.

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