Registration Form - ECG Robotics

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STUDENT INFORMATION

First Name*

Last Name*

GenderMaleFemale

Email*

Full Address *

Home Phone# (xxx-xxx-xxxx)*

Mobile Phone# (xxx-xxx-xxxx)*

Date of Birth (MM/DD/YYYY)*

School Name*

Grade (Fall 2020)*

Does this student have food or environmental allergies?YesNo

If yes, please list allergies

Does the student carry medication?YesNo

If yes, what medication?

I plan to participate in the following program (choose only one)*FIRST Robotics Competition (FRC)

Do you have any experience with (Please check all that apply)AutocadComputer AnimationGraphic DesignComputer ProgrammingWeb Page DesignElectronicsOther

If you've checked "other," please describe:

I am interested in (optional):OutreachSponsorship LiaisonMarketingFundraising

PARENT(MOM) GUARDIAN 1 INFORMATION

Name(First Name & Last Name)*

Mobile Phone# (xxx-xxx-xxxx)*

Employer

Email*

Address (if different from student)

PARENT(DAD) GUARDIAN 2 INFORMATION

Name(First Name & Last Name)*

Mobile Phone# (xxx-xxx-xxxx)*

Employer

Email*

Address (if different from student)

EMERGENCY CONTACT

(The person listed as the emergency contact should be someone other than the parent/guardian. They will be contacted in a emergency only if we cannot reach a parent or guardian)

Name (First Name & Last Name)*

Contact Phone# (xxx-xxx-xxxx)

May we link your VIC card to ECG Robotics?YesNoDo not have a VIC card

Harris Teeter VIC Card #

Student T-shirt size (adult sizes)XSXMLXL

Student Contract

Parents and student must read and agree to the student contract. Please Copy and Paste this Link to your browser.

PERMISSION TO PARTICIPATE IN ECG ROBOTICS FTC AND FRC ACTIVITIESI DOI DO NOT

I understand team meeting will be at various facilities.

Parent Consent --please click to open, sign and return

Parent/Guardian Name*

Date (MM/DD/YYYY)

PHOTO CONSENTI DOI DO NOT

REQUIRED ESSAY REGARDING YOUR INTEREST IN ECG ROBOTICS (about 200 words)*

Parent/Guardian Initials*

Student Initials

Registration Fee

$275

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