Student Registration

Academy Selected
Academy Attending: Please select the academy session you are interested in attending: Academy Session 1: June 23-26, 2019; Academy Session 2: July 7-10, 2019
Student Name First/Last *
Student Name First/Last
First/Last Name
Name you want on your name badge *
Name you want on your name badge
Date of Birth *
Date of Birth
Date of Birth
Choose year current school year from drop down.
Student Cell *
Student Cell
Complete Mailing Address *
Complete Mailing Address
Student Address
Parent / Guardian Name *
Parent / Guardian Name
Parent Cell *
Parent Cell
Please list best # available
Emergency Contact Phone # *
Emergency Contact Phone #
Member of Interact
Please indicate if your student has any medications, physical limitations, allergies, or food allergies. Are there any additional health concerns? Please list.
Medical note: 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 my require assistant or special consideration to while at the academy)
Medical *
If you answered yes to insurance question, enter your carrier and policy number. If you answered "no, waiver", enter "Waiver"
Attendance *
By checking this box, I agree to attend the full RYLA Academy
Media Release Consent *
Date 1 *
Date 1