Application Form

Submitted by adross on 18 June 2011 - 7:25pm

Applicant Details

Personal Details

Title:

Given Names:

Surname:

Gender:

Male

Female

Name by which you wish to be known:

ie. Liz

Date of Birth:

Contact Details

Email Address:

Phone (h):

Phone (w):

Mobile:

Address

Street 1:

Street 2:

Suburb:

Postcode:

Work Details

Occupation:

Employer:

Education

High School - Year Completed:

High School - Level:

Tertiary Education - Year Completed:

Tertiary Education - Description:

Successful participation in the following examinations and awards will be highly regarded, but is not a pre-requisite

Leadership Experience

Previous Leadership Experience:

Please outline your previous leadership experience. Specifically, what kind activities have you performed, what leadership positions have you held, what responsibilities did you have, and when did this occur. Feel free to list multiple examples.

Comments:

Interests

What are your other interests and achievements?:

Do you play a musical instrument?:

Yes

Type:

If practical, please bring your instrument or music with you as there are many occasions to use these

Health & Wellbeing

Do you have any special dietary needs?:

Yes

If yes, please specify:

Do you have any chronic illness or permanent disability?:

Yes

If yes, please specify:

Medicare Number:

In Case of Emergency

Name:

Relationship:

Phone Number:

I hereby make application for the Rotary Youth Leadership Award. Should my application be successful, I agree to attend the entire seven day seminar and will abide by the rules of RYLA.

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