Rotary District 7500

Rotary Youth Leadership Awards

June 25-28, 2011

Monmouth University, West Long Branch, NJ

www.ryla7500.org

Congratulations! You made it!

What is RYLA? District 7500 RYLA is an intense and fun-filled four-day leadership training program run by Rotarians and previous RYLA participants who have demonstrated superior leadership and training skills, within RYLA and in their communities. We hold our RYLA at Monmouth University in West Long Branch, NJ, usually the last weekend of June, from Saturday through Tuesday. We teach a variety of leadership skills, such as team-building, problem-solving, cooperation and communication skills. Our program is designed to help train ethical, visionary leaders. The RYLA conference is planned and run by the Rotary District 7500 RYLA Committee. Each team of about 16 RYLA participants is directly supervised by 3-4 counselors, who are typically 1-2 years older then the participants, and one Advisor who is typically 4-10 years older than the participants. Who pays for RYLA? The cost for each participant in 2011 is $420. This price includes room, meals, a tee shirt and all program expenses. Most sponsoring Rotary Clubs are paying $395 of this amount and asking the participants to contribute just $25. (Your local Rotary Club may be doing it a little differently. Ask them.) What to do now: 1. Print the .pdf file that was attached to the email, and fill out all the forms. 2. Mail them to the addresses on the bottom of the forms. (Please note that the Program Book Order Form goes to a different address.) 3. Make contact with your local Rotary Club and attend one of their regular meetings to introduce yourself. If they require it, give them a check for your co-payment (ask your Rotary Club what their policy is and how to make out the check). 4. Keep checking your email, because we will be sending other information as RYLA gets closer. We cant wait to meet you on one of the most amazing weekends of your life! Sincerely, Dave GoWell Program Director, District 7500 RYLA PS: We MUST get these forms from you before you come to RYLA.
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Rotary District 7500

Rotary Youth Leadership Awards

June 25-28, 2011

Monmouth University, West Long Branch, NJ

www.ryla7500.org

Participant Information Sheet

Participant should keep this sheet and refer to it when getting ready for RYLA Dates: Saturday, June 25, 2011 (8:45am) through Tuesday, June 28, 2011 (8:30pm) Where: Monmouth University 400 Cedar Avenue, West Long Branch, NJ 07764 (732) 571-3400 What you really need to bring: Optional items you might want to bring: Clothes for 4 days, three nights (Shorts & tee shirts are fine. Use common sense.) Sheets (for twin beds), blanket, pillow and/or sleeping bag Personal hygiene products: shampoo, soap, bath towel, washcloth, shower shoes, etc. Swim suit & swim towel, in a plastic shopping bag, labeled clearly with your name (have this readily accessible when you arrive so we can take it to the pool for you) Sunscreen (sunscreen is very important!) Exercise clothes (sneakers, gym shorts, etc.) Sweater or sweatshirt (air conditioned rooms can sometimes be chilly) Reusable sports water bottle for drinking water (this is also very important!) Alarm clock Pen or pencils & notebook Personal medications in their original containers Second pair of shoes Rain coat or umbrella Digital camera & charger No more than $20 spending money in small bills (for snacks, soft drinks, etc.) Musical instrument & sheet music, or art supplies, or sports equipment. A laptop, if you like to write (we put together a newspaper) Nicer clothes for the Reflection Ceremony on Tuesday evening (e.g. sundress, skirt, dress pants, button down shirt, tieits up to you) Participants must not bring a car to RYLA. You should be dropped off by your parents, guardians or sponsoring Rotary Club. Arrive between 8:45 and 9:00 am on Saturday. You must attend all scheduled activities. If you leave, you cannot return to RYLA. No flip flops, sandals, or open-toed shoes can be worn outside, please bring sneakers. Due to the nature of our activities, skirts and dresses are discouraged. The dormitory is air conditioned Your family can join you for dinner on Tuesday evening. The first seating begins at 5:00. The cost of dinner for non-participants is $15 per person, payable at the door. On Tuesday evening we will have a final Reflection Ceremony at 6:30pm. Your family and friends are welcome to attend. There is no charge. You can place ads in the Reflection Ceremony Program Book: $5 for 1 line, $60/halfpage, $100/full-page. See the Program Book Order Form on page 8 for details.

Important Info:

Contact For more information about RYLA please visit: http://www.ryla7500.org or contact: Info: Eric Stofman estofman@aol.com (W) 856-667-4567; (Fax) 856-667-5094 David GoWell davegowell@gmail.com (W&H) 856-439-1610; (Cell) 856-313-7771
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Rotary District 7500

Rotary Youth Leadership Awards

June 25-28, 2011

Monmouth University, West Long Branch, NJ

www.ryla7500.org

Notice of Health Information Practices

Participants Copy
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Understanding Your Health Record Information Each participant in the RYLA program must complete a health history form. This record contains health and medical information generated by you for use if and when needed during the RYLA program. In this notice Notice of Health Information Practices, we shall refer to the information contained in your record as your health information. This term shall have the same meaning as protected health information defined in the Health Insurance Portability and Accountability Act of 1996, as amended (HIPAA). Your Health Information Rights Within the limits provided by federal and state law, you have the right to: Request restrictions on certain uses and disclosures of your health information; Receive confidential communications of your health information. You may request that we communicate with you about your health information by alternative means or at an alternative location; Inspect and obtain a copy of your health information, except with regard to psychotherapy notes or information compiled in reasonable anticipation of certain civil, criminal or administrative proceedings; Request an amendment to your health information that you have created. Obtain an accounting of certain disclosures of your health information; and Receive a paper copy of this Notice in addition to any electronic copy you may receive. You may exercise any of the above rights by submitting a request in writing to our Registrar. Our Responsibilities The RYLA program is required by law to: Maintain the privacy of your health information; Provide you with this Notice of our legal duties and privacy practices with respect to health information we collect and maintain about you; Abide by the terms of this Notice, currently in effect, and as amended from time to time; Notify you if we are unable to honor your request to restrict a use or disclosure of, or to amend, your health information; and Accommodate reasonable requests you may have to communicate your health information by alternative means or at alternative locations. As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Upon request, we will provide you with the most recently revised notice. Your Rights regarding your Personal Health Information You have the following rights regarding the information that we have received from you: Confidential communications. You have the right to request that our program communicate with you about your health related issues in a particular manner or at a certain location. Requesting restrictions. You have the right to request a restriction in our use or disclosure of your information for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request, however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your information, you must make your request in writing to our Registrar. Your request must describe in a clear and concise fashion: 1. The information you wish restricted, 2. Whether you are requesting to limit our programs use, disclosure or both, 3. To whom you want the limits to apply.

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Rotary District 7500

Rotary Youth Leadership Awards

June 25-28, 2011

Monmouth University, West Long Branch, NJ

www.ryla7500.org

Notice of Health Information Practices

(continued) Participants Copy
More information or to Report a Problem If you would like to submit a comment or complaint about our privacy practices, please contact our Registrar: Eric Stofman RYLA Registrar 1060 N. Kings Hwy, Suite 110 Cherry Hill, NJ 08034 (856) 667-4567 You may also file your complaint with the Secretary of Health and Human Services. You will not be penalized or otherwise retaliated against for filing a complaint. Examples of Uses and Disclosures for Treatment, Payment and Health Operations The following are examples of uses and disclosures of your health information which are permitted by law: We will use your health information for treatment We will use your health information to provide medical services to you if necessary. Any of our staff involved in your care or seeking care on your behalf will have access to your health information. We may also provide your health information to other health care providers involved in your care to assist them in providing services to you. However, we will not disclose psychotherapy notes or information to health care providers who are not the originators of that information unless we have your written authorization to do so. We will use your health information for regular health care operations. Members of our staff may review and use information from your record to assess the care and outcomes in your case and others like it. Communication with Persons involved in Your Care: We may disclose your health information that is directly relevant to your care to individuals involved in your care and individuals you wish to receive such information, including family members, relatives, close personal friends, or other persons you identify. Before we do so, we will ask you, and follow your instructions, as to whether or not to make such disclosures. If you are incapacitated, or involved in an emergency, we may use or make disclosures of your health information that we believe in our judgment are in your best interests, but only to the extent that such health information is directly relevant to the recipients involvement in your care. Required by Law: We may use or disclose your health information to the extent such use or disclosure is required by law and is limited to the relevant requirements pf such law. Victims of Abuse, Neglect or Domestic Violence: If we reasonably believe that you are the victim of abuse, neglect or domestic violence, we may disclose your health information to a governmental authority responsible for receiving these types of reports, to the extent the disclosure is required by law, or you agree to the disclosure. If the disclosure is authorized by law, but not required, we may disclose your information if we determine that disclosure is necessary to prevent serious harm to you or others. For all other circumstance, we may only use or disclose your health information after you have signed an authorization. If you authorize us to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time. Our Pledge We will endeavor to protect the privacy of your health information. If you have any questions, comments, or concerns regarding the policies set forth above, please do not hesitate to discuss such matters with the contact named above.

Keep this copy for your records

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Rotary District 7500

Rotary Youth Leadership Awards

June 25-28, 2011

Monmouth University, West Long Branch, NJ

www.ryla7500.org

Consent to Use or Disclose Information for Treatment, Payment, and Health Care Operations
(Please type or print)

Participants Name: ______________________________________________

Federal regulations allow us to use or disclose protected health information from your Health History form in order to provide treatment to you if necessary, and for other professional activities known as health care operations (for example, quality improvement activities). With this consent form, we are asking you to make the permission explicit. By signing this consent, you are giving us permission to use or disclose your protected health information for these activities. These uses and disclosures are described more fully in our Notice of Health Information Practices. You have the right to review that Notice before signing this consent. We reserve the right to revise our Notice of Health Information Practices at any time. If we do so, the revised Notice will be available at the registration desk on the first day of the RYLA program. You may ask for a printed copy of our Notice at any time. You may ask us to restrict the use and disclosure of certain information in your record that otherwise would be allowed for treatment, or health care operations. However, we do not have to agree to these restrictions. If we do agree to a restriction, that agreement is binding. I wish to have the following restrictions put on the use or disclosure of the health information:

You may revoke this consent at any time by giving written notification. Such revocation will not affect any action taken in reliance on the consent prior to the revocation. This consent is voluntary; you may refuse to sign it. However, we are permitted to refuse to provide health care services if this consent is not granted, or it the consent is later revoked. I hereby consent to the use or disclosure of the above named RYLA Participants protected health information as specified above. Participants Signature: ______________________________________________________________Date: __________________ Parent/Guardian Signature: ___________________________________________________________Date: _________________ Parent/Guardian Name: (please print) ___________________________________________________ Make a copy of this form for your records and mail original signed form by June 5th to: Eric Stofman RYLA Registrar 1060 N. Kings Hwy Suite 110 Cherry Hill, NJ 08034 (856) 667-4567

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Rotary District 7500

Rotary Youth Leadership Awards

June 25-28, 2011

Monmouth University, West Long Branch, NJ

www.ryla7500.org

Acknowledgement of Receipt of Notice of Health Information Practices

(Please type or print)

Participants Name: ___________________________________________

I have received a copy of the Notice of Health Information Practices for the Rotary District 7500-RYLA. I understand that RYLA reserves the right to modify these practices, if necessary, or as required by law.

Parent/Guardian Signature: ___________________________________________________________Date: _________________

Parent/Guardian Name: (please print) _______________________________________________________________

Parental/Guardian Authorization
I give my consent for my son/daughter, listed above, to participate in the Rotary District 7500-Rotary Youth Leadership Awards program (hereinafter called RYLA) and do hereby release and hold harmless District 7500, the RYLA Committee, the RYLA staff, the sponsoring Rotary Clubs, and Monmouth University from any and all liability. In case of emergency I hereby give permission for RYLAs medical team to secure and provide whatever health services are determined necessary for our sons/daughters health, including dispensing any medications that the medical team determines is in my son/daughters best interests. I understand that the RYLA staff will be taking photos of events at RYLA and understand that my son/daughter may appear in some of those photos and I give permission to use these photos on the RYLA website, in RYLA brochures, etc. I understand that there are a few firm rules at RYLA, for example, attending all activities, not being out of the dorms after-hours, not texting during programs, respecting the campus property, etc. and agree that if my son/daughter repeatedly breaks these rules that I am responsible to come get him/her immediately and take them home.

Parent/Guardian Signature: ___________________________________________________________Date: _________________

Health Insurance Information

Is the participant covered by Health or Accident Insurance: Yes No

Type of Coverage: __________________________________ Company: _________________________________________ Group #: ___________________________________ Policy #:___________________________________________

Policy Holder Name:________________________________ Social Security #:____________ _______________________

Make a copy of this form for your records and mail original signed form by June 5th to: Eric Stofman RYLA Registrar 1060 N. Kings Hwy Suite 110 Cherry Hill, NJ 08034 (856) 667-4567

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Rotary District 7500

Rotary Youth Leadership Awards

June 25-28, 2011

Monmouth University, West Long Branch, NJ

www.ryla7500.org

Participants Health History

(Please type or print)

Participants Name: ___________________________________________ Male Female

Date of Birth: _______________

Height: _______

Weight: ________

Sex:

Participants Mailing Address: __________________________________________________ City: ______________________________________ State: NJ Zip: ____________

Phone #:______________________

Another Phone #:____________________

Physician: __________________________________________________ Physician Phone #: _______________________________ Do you have, or have you had, any of the following? (Check yes or no) Allergies to Medication Yes No Allergies to Food Yes No Allergies (Seasonal) Yes No Allergies to Bee Stings Yes No Asthma Yes No Asthma (Exercised Induced) Yes No Back Problems Yes No Bleeding Disorders Yes No Diabetes Yes No Do you Smoke Yes No Epilepsy Yes No Fractured Bones Yes No Head Injury Yes No Hearing Problems Yes No Heart Disease Yes No Hepatitis Yes No Hernia Yes No High Blood Pressure Yes No Infectious Mononucleosis Yes No Joint Problems Yes No Kidney Disease Yes No Skin Diseases Yes No Surgery Yes No Thyroid Disease Yes No Under Doctors Care Yes No Recent Upper Respiratory Infection Yes No Varicella (chicken pox) Yes No Wear Glasses or Contacts Yes No Other: ________________________________________________ ________________________________________________ ________________________________________________

If you answered YES to any of the above, PLEASE EXPLAIN in detail. (ie: Broken Left Wrist in 2004, airborne allergy to peanuts): __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ If taking ANY Medications PLEASE list ALL names, doses, and frequency, and if you will be taking them throughout RYLA (Example: Advair 150/50 twice a day for asthma, carry an Epi Pen for bee allergy): ________________________________________ ___________________________________________________________________________________________________________ Immunizations: DPT Polio MMR Tetanus Booster Hepatitis Other: ___________________________________ Recent Hospitalizations: Date and Reason: ______________________________________________________________________ Having read and answered the above I hereby declare that I have had no injury, illness, or aliment other than as specifically herein noted. I understand that any falsification or misrepresentation will be sufficient grounds for my release from this conference. Parent/Guardian Signature: ___________________________________________________________Date: _________________ Make a copy of this form for your records and mail original signed form by June 5th to: Eric Stofman RYLA Registrar 1060 N. Kings Hwy Suite 110 Cherry Hill, NJ 08034 (856) 667-4567
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Rotary Youth Leadership Awards

District 7500

Program Book Order Form

The Rotary Youth Leadership Awards (RYLA) is a non-profit youth leadership development program available to high school students through Rotary International. Rotary is a worldwide organization of more than 1.2 million business, professional, and community leaders providing humanitarian service, encouraging high ethical standards in all vocations, and helping build goodwill and peace in the world. Each year, young men and women from Monmouth, Burlington and Ocean Counties are trained in a variety of leadership skills. Some of these lessons include communication skills, goal setting, team building, problem solving and many other personal development skills. District 7500 RYLA will take place June 25th - 28th at Monmouth University. You can learn more about our mission by visiting our website at www.ryla7500.org. We are seeking local program support by selling ad space in our 2011 Reflection Ceremony Program Book. By placing an ad in this booklet, your company will have exposure to more than 250 families in Monmouth, Burlington, and Ocean Counties. Please send electronic copies of ads to: kevin.j.pons@gmail.com as a .JPEG, .PDF, or Word Doc. If you have trouble with those formats, please contact Kevin and he can work with you directly. District 7500 would like to thank you in advance for your contribution. Our program would not be possible without your generous support.

Please return this form and payment by June 15, 2011 to:

Kevin Pons 1 Westbrook Drive, Apt O-206 Swedesboro, NJ 08085

Company Name : ________________________________________________________________________________________ Address: _______________________________________________________________________________________________ Contact: ____________________________________________ Telephone: ________________________________________ Email: _____________________________________________ Website: __________________________________________ _____ Full Page _____ Half Page _____ One Liner* $100.00 Payment Type: ____ Check $60.00 ____ Cash $5.00 *One Liners are limited to 75 characters including spaces and punctuation. (payable to: District 7500 RYLA) (please do not mail cash)

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Directions to
Monmouth University 400 Cedar Avenue, West Long Branch, NJ 07764 (732) 571-3400 From NORTH on 295 (or NJTP) to 195 EAST to Garden State Pkwy (GSP) NORTH Burlington GSP NORTH to Exit 105 (Rt 36 East) County: See directions below from GSP Exit 105 From Take Garden State Pkwy NORTH Ocean to Exit 105 (Rt 36 East) County: See directions below from GSP Exit 105 From GSP From the Garden State Pkwy go EAST on Exit 105: Rt 36 for about 3 miles Turn SOUTH onto Rt 71 (Monmouth Rd) Monmouth Rd becomes Cedar Ave (bear left at fork) Follow Cedar Ave to college

Pass the Main Entrance on the right Turn LEFT through large white gates Follow RYLA signs back to parking lot behind dorms. PLEASE arrive between 8:45 and 9:00am on Saturday!

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Map of Monmouth University

Parking Dorms White Gates Dining Hall

Wilson Hall Main Entrance Cedar Ave

Gym & Pool

Pollak Theatre

Student Center

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