Season Registration – Bot N Brick

2023-2024 Season Registration
Contact
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2023-2024 Season Registration
Contact
Donate

FLL and FTC Season 22-23 Registration and Medical Information

Student Name

Student Age

Date of Birth

Name of School

Grade

Parent/ Guardian Name

Parent/Guardian Email

Parent/Guardian Phone

Address

Emergency Contact 1 Name

Emergency Contact 1 Relationship

Emergency Contact 1 Phone

Emergency Contact 2 Name

Emergency Contact 2 Relationship

Emergency Contact 2 Phone

Health Insurance?

Yes No

Insurance Provider

Group Plan # or ID#

Insurance Phone

Contact lenses/Glasses?

Yes No

Hearing Aids?

Yes No

Does the student have Asthma?

Yes No

Please specify medications and restrictions:

Does the student have a heart condition?

Yes No

Please specify medications and restrictions:

Is the student on any medication?

Yes No

If so, indicate medication, dosage, condition prescriibed for and any known negative drug interactions:

Does the student have any allergies to food, animals, medications or other (ie bees, peanut butter, aspririn, etc.)

Yes No

If so, please give specific reaction to each allergen and degree of sensitivity (10 being deathly allergic and 1 being mildly)

Does your student have medication for allergic reactions (ie EpiPen, Benadryl, etc)?

Yes No

If so, what?

Does the student have any physical disabilities, conditions, or limitations that could become a problem?

Yes No

If so, please describe the disability/limitation and history:

Are there any other special circumstances or conditions that our staff should know about while your student is participating in HLCC Robotics Events?

Download Consent Forms

Please Click the button to Download, Print, Fill Out and Bring consent forms to the first day of the season. We will have a notary on site.

Download Consent Forms