SC/Rotary Leadership Camp Application Form

2015 Rotary Leadership Camp

Through the camp you will learn about yourself and others and about motivation and teamwork. Learn more about camp specifics by visiting or by emailing or calling (620) 229-6367 with questions.

The camp will be May 27-May 31, 2015 (Wednesday - Sunday), on the Southwestern College campus.

Deadline for sign-up is Friday, May 6, 2015. Cancellations prior to May 13th result in half refund of camp fees; no refunds after Wednesday, May 13th.

If seeking scholarship funding from your local Rotary Club, you are responsible for contacting your club and requesting payment. Contact if you are uncertain about how to contact your local club.

The SC Leadership Rotary Camp is implemented through a partnership with RYLA. Rotary Youth Leadership Awards (RYLA) is an intensive training program that brings together youth and young
adults, ages 14-30, to further develop character and leadership skills and learn about Rotary.


Biographical Information

Last Name  
First Name  
Street Address  
Zip Code  
E-mail Address  
Phone Number  
Gender  Male
Shirt Size

High School  
Class of  

Do you have any special dietary needs?

Why would you like to attend the camp?

Parent Information

Last Name  

First Name  

Email Address  

Home/Cell Phone  

Work Phone  


The week of camp, including housing and expenses, costs $300. Scholarships, which may cover the full cost of the camp, are available through local Rotary clubs. Local clubs must be notified by the applicant and scholarship requests approved prior to May 6th.  All payments are due by May 13th.

Please make checks payable to:  Rotary Youth Leadership Camp  

Send to:

Community National Bank & Trust
Attn: Rotarian, Dean Kennedy
P.O. Box 637
Winfield, KS 67156

Method of payment:

Full scholarship payment to be made by Rotary Club


Partial scholarship payment by Rotary Club and partial payment made by individual
(Please indicate:  $ by Rotary Club & $ by individual )


Full payment to be made by individual


Other payment method (i.e. Legacy Foundation)
(Please explain:  )


Sponsoring Rotary Club (if applicable)
*You are responsible for contacting your club to request payment prior to May 6th.

Photo and Video Release

It is vital that the SC Rotary Camp keeps updated records of events and an active website which may contain student's photos. Names of students will never be identified.

I GIVE permission to Southwestern College Rotary Camp to use my  photograph for the school's and Rotary International's promotional material.

I DO NOT give permission to Southwestern College Rotary Camp to use my  photograph for the school's and Rotary International's promotional material.


In consideration of my entry being accepted I, intending to be legally bound, do hereby waive, release, and forever discharge any and all rights and claims for damage which hereafter occur to me against Leadership Southwestern, Southwestern College, Rotary District 5690, Winfield Rotary Club, and all sponsors, volunteers for any injuries suffered by me against this event. I further state that I am in proper physical condition to compete in this race.

By typing my name in the Signature textbox below and submitting this online form I certify under penalty of perjury that all information provided is correct and complete and I agree to the terms and conditions of the waiver stated above.


Signature of Parent/Guardian:     


Southwestern College is committed to a policy of nondiscrimination on the basis of race, color, gender, age, religion, national origin, handicap, or other nonmerit reasons, in admissions, educational programs or activities, and employment, all as required by applicable laws and regulations. Responsibility for coordination of compliance efforts and receipt of inquiries, including those concerning Title IX of the Education Amendments of 1972 and Section 504 of the Rehabilitation Act of 1973, has been delegated to the vice president for business affairs, Christy Administration Building, Southwestern College, 100 College Street, Winfield, KS 67156-2499, (620) 229-6000. Southwestern College complies with the Crime Awareness and Campus Security Act of 1990. The yearly report is available from the dean of students upon request. Race and ethnic origin information is voluntary and will not be used in a discriminatory manner.