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This Expression of Interest for the Rotary Youth Program of Enrichment should only take you about 10 minutes to complete and should be completed by a parent/guardian. We collect this information to help us connect you to a Rotary Club so that they can formally consider your interest and provide sponsorship.

Have the following information available to complete the EOI:

Your personal information including contact details and date of birth
If you have been in contact with a Rotary Club and their contact details if you have

The information is collected to assist with the RYLA application process and management of the conference. Further details about how we use your personal information is provided at the end of this form and on our website.

For more information about how Rotary International District 9790 Inc. (ABN 48335105362) uses your personal information, see our Privacy policy.

Student details

First name*

Surname*

Preferred name

Address*

Street Address Town/Suburb State Post Code

Date of birth*

Month

Day

Year

Year Level*

Please enter a number from 8 to 11.

School name*

Include campus if the school has multiple campuses

Pronouns*

She/Her

He/Him

They/Them

Prefer not to answer

Other

Gender*

Woman or female

Man or male

Non-binary

Prefer not to answer

Other

Do you identify as cis or trans?*

Cis includes persons whose gender is the same as their sex recorded at birth.

Cis

Trans

Prefer not to answer

For more information about pronouns and why we are asking, see: Minus18

Are you of Aboriginal and/or Torres Strait Islander origin?*

For persons of both Aboriginal and Torres Strait Islander origin, mark both responses: Yes Aboriginal, and Yes Torres Strait Islander.

Yes, Aboriginal

Yes, Torres Strait Islander

Parent details

Full name*

Email*

This email will be used for confirmation and communication.

Mobile Phone*

We may contact you by phone or text to send updates about the conference or in case of an emergency.

Name of person to contact in an emergency (if different from the parent/carer):

Please ensure the person you list here is aware you have provided their contact information for this purpose.

Emergency contact's mobile phone

About you

Please be as detailed as possible in this section as your responses will be sent to a Rotary Club to assist them when considering your application. If your answers are not detailed enough we may come back to you to ask for more.

What are your main interests at school?*

What are your main interests outside of school?*

Are you currently in contact with a Rotary Club that has indicated interest in sponsoring you?*

If NO, your application will be included in a “pool” of applicants and we will seek to find a sponsoring club on your behalf.

Yes

Sponsor Club

Your form will be automatically sent to the sponsor club so please ensure that you enter these details carefully, especially the email address. If you don’t have this information please save the form, confirm the info and come back. Your sponsorship cannot be processed without this information!

Name of Sponsor Club:*

Just enter the club’s name, not the “Rotary Club of” bit. For example, “Rotary Club of Anytown” is just “Anytown”.

Name of your contact in the club:*

Contact's Email:*

Confidential medical report

Rotary International District 9790 (Rotary) requires the information requested in this form for all students participating in camps, to plan for and support the health care needs of students. This form is to be completed by a parent/carer prior to their child going on a camp (residential program). The information provided must be current at the time of the camp. Parents/carers will also receive detailed information about the excursion/program prior to participation and be provided with a parent consent form. Any questions about excursions will be answered by the school.

First Aid and Medical Assistance

If there is a situation or incident which requires first aid to be administered to a student, Rotary staff will administer first aid that is reasonably necessary and appropriate to their level of training. Rotary staff will also seek emergency medical attention for a student if it is considered reasonably necessary. In the event that a student needs medical attention during the camp, Rotary staff will contact their parent/carer as soon as practically possible. Parents/carers are responsible for all medical costs if a student becomes ill or injured on camp unless it is found that the illness or injury was caused by Rotary failing to discharge its duty of care. For camps, parents/carers can purchase student accident insurance cover from a commercial insurer if they wish to.

Privacy Statement

The personal and health information collected in this form, and attachments, will be managed securely and accessed only by staff and volunteers, on a need-to-know basis, and in accordance with our privacy policy and the law. In the event of a medical emergency, information will be provided, as required, to emergency services and medical practitioners.

MedicAlert number (if relevant):

MedicAlert is a 24/7 international emergency response service that shares your vital information directly to those who need it.

Medical/hospital insurance fund:

Member number:

Ambulance subscriber?*

I understand that if I am not an Ambulance subscriber, I will be personally liable for any costs associated with calling an ambulance.

Yes

Ambulance subscriber number:*

Is this the first time your child has been away from home?*

Yes

Medical History

Please tick if your child is living with any of the following health conditions:

Asthma

Anaphylaxis

Bed wetting

Blackouts

Diabetes

Dizzy spells

Heart condition

Sleepwalking

Travel sickness

Seizure of any type

Other

Medical action plan*

Please upload copies of asthma, Anaphylaxis or Diabetes, etc. action plans.

Drop files here or

Max. file size: 80 MB.

Provide details of the other diagnosed medical or mental health condition:*

Allergies

Please tick if your child is allergic to any of the following:

Penicillin

Other Drugs

Foods

Other allergies

Please describe the allergy and what special care is recommended for these allergies?*

Year of last tetanus immunisation:*

Tetanus immunisation is normally given at five years of age (as Triple Antigen or CDT) and at fifteen years of age (as ADT)

Please enter a number from 2000 to 2100.

Surgical History*

Has your child had any past or upcoming surgeries?

Yes

Please provide more information including age of child at the time of surgery, nature of surgery:*

Medication*

Is your child taking any medicine(s)?

Yes

Please provide the name of medication, dose and describe when and how it is to be taken.*

All medication must be given to the Rotary member at pick-up. All containers must be labelled with your child’s name, the dose to be taken as well as when and how it should be taken. The medications will be kept by Rotary staff and distributed as required. Inform the Rotary member if it is necessary or appropriate for your child to carry their medication (for example, asthma puffers or insulin for diabetes). A child can only carry medication with the knowledge and approval of both the Rotary member and their parent/carer.

Further Information

Is there anything else about your child’s health and wellbeing or medical history that is important for us to know?

Consent

Adventure activities to be undertaken or that may be offered to students throughout the program:
-Artificial climbing and abseiling walls
-Challenge ropes courses

Activities within this program present the potential for students to sustain physical injury. A risk management plan for this program has been developed by staff and is available for parents to review on request.

I understand that in the event of my child’s misbehaviour or behaviour that poses a danger to themself or others during the event, they may be sent home. I further understand that in such circumstances I will be informed and that any costs associated with their return will be my responsibility.

I understand that in the event staff determine it is necessary for my child to be sent home early due to illness, any cost associated with their return will be my responsibility.

Rotary does not provide student accident insurance or ambulance cover. Parents may wish to obtain student accident insurance from a commercial insurer and/or ambulance cover, depending on their health insurance arrangements and any other personal considerations.

I give permission for my child to attend.

Release and Indemnity*

I, the above named parent/guardian of the above named student am aware and acknowledge that participating at the Rotary International District 9790 Rotary Youth Program of Enrichment (RYPEN) involves inherent risks, including the risk of injury to life or death and damage to property and in undertaking such activities, I do so at my child’s own risk.

I am also aware that it is a condition of participation at RYPEN that Rotary International (Rotary), their officers and employees, agents and volunteers are released by me from all liability howsoever arising from injury or damage to both property and person howsoever caused (whether fatal or otherwise) arising out of my child’s participation at RYPEN whether or not such injury or damage is due to any negligent act, breach of duty, default and/or omission on the part of Rotary, their officers and employees, agents or volunteers.

I indemnify Rotary, their officers and employees, agents and volunteers against all loss, damage and expenses (including legal costs on a solicitor and own client basis) arising out of or in connection with any claims, actions, proceedings or demands of any kind arising directly or indirectly as a consequence of my child’s participation at RYPEN.

In the case of an emergency I authorise Rotary, where I am unable to be consent, to arrange for me to receive medical or surgical treatment as deemed necessary. I also consent to undertake any payments or reimburse costs which may be incurred for medical attention, ambulance transport and medication while I am in Rotary’s care.

I acknowledge and agree that my child’s participation at RYPEN is as a consequence of their own free will and desire and that I have read and understood the above warning, release and indemnity.

I warrant that I am 18 years of age or older and am lawfully able to enter into this above release and indemnity on behalf of my child.

I agree to the Release and Indemnity.

Privacy statement*

Rotary International District 9790 (Rotary) will collect and store the information you voluntarily provide. The information will be stored in a manner so that it will only be accessed by authorised Rotary Volunteers, and subject to privacy restrictions. The information is collected to assist with the RYPEN application process and management of the conference. Some of this information will also be provided to Rotary Clubs to provide sponsorship for your place at the conference and to medical professionals where necessary.

Rotary is committed to protecting the privacy and confidentiality of your personal information. Our privacy policies adhere to the National Privacy Principles, as required under the Privacy Act 1988 (Cth). A copy of our privacy policy is available online at http://rypen.org.au/privacy/.

We use Microsoft 365 to collect and store your information; for information about the security of Microsoft 365 see: Privacy at Microsoft.

I agree to the privacy statement.

Media consent

Rotary International (Rotary) would like your consent to take photos and/or video your child at the Rotary Youth Program of Enrichment (RYPEN) conference.

During the event your child may be photographed or videoed in activities such as:
• attending this program or event
• talking about the program listed above

Consent is when you agree to something.

You are giving us consent to use these photos or video:
• on our websites and social media
• in information or advertising about the Doxa Youth Foundation and/or Rotary International
• in newsletters or other communications to the public

Your child’s privacy
Photographs and film of a person that may be capable of identifying the person may constitute a collection of ‘personal information’ under Australian privacy law. Rotary values the privacy of every person and must comply with Australian privacy law when collecting and managing all personal information.

Ownership and Reproduction
Copyright in the images will be wholly owned by Rotary. This means that Rotary may use the images in the ways described in this form without notifying, acknowledging or compensating you.

What you are agreeing to
• you have read this information
• you give us consent to take photos or video of your child
• you understand that we may use the photos or video of your child in the ways we list above
• your consent starts from the date you submit this form.

Withdrawing your consent
If you want us to stop using the photos or video of you, you must tell us by emailing info@ryla9790.org.au.

We will not use them again, but we may not be able to remove them from things that have already been published.

I agree to the media consent.

Signature

I have read all of the above information provided by Rotary in relation to the Rotary Youth Program of Enrichment.

Apply to attend RYPEN

Student details

Parent details

About you

Sponsor Club

Confidential medical report

First Aid and Medical Assistance

Privacy Statement

Consent