Registration Form for Youth Participant

2017 CONFERENCE ROTARY CLUBS OF THE BAHAMAS, DISTRICT 7020 24th – 26th February, 2017 | Nassau, Bahamas

REGISTRATION FORM FOR YOUTH PARTICIPANT

Last Name: First Name: Nick Name: Gender: Age: Home Address: Home Tel Number: Mobile Number: E-mail (Required): T/shirt Size: Name of Parent/Guardian with whom you reside: Postal Address of Parent/Guardian: Parent/Guardian Home Tel Number: Work Number: Name of Interact Club (School you attend): Name of Club Advisor: Grade/Class Level: Club Memberships, School Service, Civic/Social Organization(s):

Physical Limitations: Medical/Dietary/Special Requirements:

Emergency Contact: Tel Number: Sponsored By Rotary Club:

______Date: ______Signature of Parent/Guardian (for participants under 18 yrs)

INDEMNITY CLAUSE : Except in the case of any death or personal injury suffered by a participant as a result of negligence as defined in the Unfair Contract Terms Act Chap. 82:37, all RYLA 2017 participants shall indemnify and continue to indemnify and hold harmless Rotary District 7020 and its representatives (which expression includes and is not limited to all officers and members in each Rotary Club constituted under the rules and regulations of Rotary International as “Rotary District 7020” as well as their employees, agents, assigns and successors ) against all claims, proceedings, costs, expenses, liabilities, personal injuries, death, loss or damage, (of whatsoever kind and nature and howsoever caused), whether to the participant’s person or property or reputation , relating to or arising out of or as a consequence of the participant’s travel to and from, attendance at, presence or participation in, whether directly or indirectly, in RYLA 2017. Registration Cost: $100.00 Registration Deadline:16 December, 2016 Three-Day Conference All-Expense Paid Inclusive of Accommodation | Meals |All Activities & Tours I etc.

Official Use – to be completed by Registrar All Forms must be submitted to the Registrar Sponsoring Rotary Club Fee Paid ____ Yes ____ No Cheque# ______Rema Martin Parent’s Consent ____ Yes ____ No Office: 1-242-397-2115 Mobil: 1-242-357-9857 Medical Release ____ Yes ____ No Email: [email protected]/[email protected] Hotel ______Room#______

RYLA Bahamas 2017 District 7020 RYLA – 24th – 26th February 2017 | Nassau, Bahamas