Application to Livingston Robotics Club Season Part A: Student information. Name: (Student) Home Address:

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1 Due s: July 30, 2017 for FLL and FTC Mail to: P.O. Box 771, Livingston, NJ to Application to Livingston Robotics Club Part A: Student information Name: (Student) Home Address: Street City State Zip Code Home Phone: _ - _ - Cell Phone: _ - _ - Student of Birth: //_ Age as of January 1, this year: Division interested: Gender: M_, F_ FIRST LEGO League Jr (FLL Jr., ages 6-9, Team Application only) FIRST LEGO League (FLL, ages 9-14) FIRST Tech Challenge (FTC, 7th grade 12th grade); LRC Shining Star Program (for Jr. FLL or FLL with learning differences) School/Grade as of September this year: School, Grade Prior FIRST experience (if any): I was on a FLL Jr. Team, Year to I was on a FLL Team, Year to I was on a FTC/VEXTeam, Year to Your role(s) on the team: Reasons for applying to LRC Prior robotics or science experience: Yes No LEGO WeDo, LEGO Mindstorms, TETRIX, VEX Programming experiences/lessons: EV3 RobotC; JAVA; LabView; Other () Robotics Club or Center, specify Science competition, specify Extracurricular and School Activity: (sports, music, scouts, dance, language, club, tutoring, etc.) Activity 1: ; Activity 2: ; Activity 3: ; Activity 4: ; Activity 5: ; Activity 6: ; 1

2 Part B: Parent Information Primary Contact Name: (Father or Mother) Cell Phone: _ - _ - Occupation: Employer: Secondary Contact Name: (Father or Mother) Cell Phone: _ - _ - Occupation: Livingston Robotics Club is a non-profit, parent volunteer organization. Parents are the most important part of the club. All parents are expected to assist and support in different ways. Lack of active parental involvement or positive support in the team activities, may resulted in member not be invited back to the team. Please select at least one parent duty function that you can help the team (check all that applies): Coaching: No prior experience necessary, but some technical background would be helpful Basic LEGO Model building, WeDo (for Jr.FLL) Mindstorms construction and programming (for FLL) Science Project research and presentation (for FLL) Mechanical and electrical engineering, programming, CAD, machining (for FTC) _ Team organizer (meeting schedule) _ Graphics design, T-shirt, logo _ Treasurer (collect and track team fees and expenses) _ Photography _ Video Editing _ Public Relation, Press Release, _ Website blogging _ Fundraising _ Car Pooling _ Food and Snacks _ Event Chaperone _ Other, please specify: LRC Volunteer Opportunities: Your expertise and interest to assist in mentoring the team or LRC (check all that apply): _ Engineering or Science mentor (what kind) Accounting _ Video Making & Editing _ Webpage Development & Maintenance _ Public Relations (writing news releases) _Event Planning _ Fundraising _ Grant Application _ Committee Officer _ Others 2

3 Part C: Team Matching For FIRST LEGO League and FIRST Tech Challenge Only Commitment/Team Type (choose one from each group): Commitment Level: Level A - Best effort and top priority commitment all the way! Level B - Learning and taking the challenge seriously Level C - Explore new skills as in any other extra-curriculum activities Team Type Interested: Level 1: Non-competitive Level 2: Recreational Level 3: Enrichment Level 4: Competitive Level 5: Highly Competitive Students: Commitment Level ; Team Type Parents: Commitment Level ; Team Type Team Meeting Schedule Availability (provide 3 time slots): Team meeting location and schedule are determined by the coaches based on the availability of most of the members. The meetings are usually conducted at coach s house or at LRC location. Below is to indicate your preferred days of week and time: Monday, Tuesday, Wednesday, Thursday, Friday, Sunday, Saturday, Medical concern, dietary restriction or allergies: Specify Code of conduct in the team: Any verbally or physically threatening, bullying, misconduct, inattention, underperformance, missing team meetings, will result in termination from LRC and the team at the discretion of the team coach without a refund of the team fee. Signature: I have read Part A to Part C carefully, and understand the requirements, obligations and involvement required. Student s Name (print) Signature (mm/dd/yyyy) Parent s Name (print) Signature (mm/dd/yyyy) 3

4 Part D: Picture & Video Authorization During the FIRST LEGO League season, pictures and videos will be taken of the students participating in the team activities or competition events, usually by the coaches, other parents, team members, reporters or other event personnel attending the functions. Photos and videos may be printed and/or released in newspapers, school publications, Livingston Robotics Club website, Landroids website and Facebook, presentations, club or team brochure, and announcements, YouTube or any other media or publications. Name of Student _ Yes, I/we, give permission for my child s picture and videos to be taken during the team meetings, functions and events, and to be published as noted above. Exceptions for publication: No; picture and video permission is not granted. Parent Signature 4

5 Part E: Consent Release, Hold Harmless This is a Consent and Release of Rights in favor of the Livingston Robotics Club, Inc. (LRC) and its officers, coaches, advisors, mentors, team parents, volunteers, employees and assigns as well as entities designated and approved to assist LRC in managing, contracting, sponsoring, hosting, conducting, evaluating or publicizing. As used below, Participant shall mean any individual, student, parents involved in a LRC Event (team meetings, team activities, field trips, tournaments, events, and exhibitions, etc). In consideration of the acceptance of my child and me participation in Livingston Robotics Club, I agree to the following: There are risks inherent in participating in Events, any team and/or Livingston Robotics Club activities, including the risks inherent in the construction of robots and LEGO structures, as well as in working with electrical power, mechanical parts, machine and power tools, traveling to and from events, and participating in public competitions. These risks include the risk of bodily harm (including without limitation, death) and property damage. Being fully cognizant of the risks in participating in an Event, I hereby assume those risks and WAIVE ANY CLAIMS OR CAUSES OF ACTION which I may now or hereafter have against Livingston Robotics Club arising out of my participation in any club meetings and activities, and I will indemnify and hold harmless against Livingston Robotics Club any and all claims resulting from such participation. I HEREBY RELEASE Livingston Robotics Club and their respective coaches, successors, affiliates, team members and parents, licensees and assigns, from all claims, demands, liabilities, damages, costs and expenses attorneys' fees, other professional fees and medical expenses, and any claims including, without limitation, claims for compensation, defamation, or invasion of privacy, or other infringements or violations of personal or property rights of any sort whatsoever that I may now or hereafter have against Livingston Robotics Club arising in connection with my participation in any Club activities. In the event I should sustain injuries or illness while involved in an Event, I hereby authorize team coaches and team parents to administer, or cause to be administered, such first aid or other treatment and medications I may bring as may be necessary under the circumstances, to include treatment by a physician or hospital. This Release shall be binding upon my heirs, personal representatives and assigns, and me and shall be governed by and construed under the laws of the State of New Jersey, which shall be the venue for any legal action. This Release constitutes the entire agreement among the parties hereto with respect to the subject matter of this Release and supersedes any and all previous agreements among the parties, whether written or oral, with respect to such subject matter. I understand that this form involves a release of legal rights. Participant/Student Name [Print Clearly] Participant/Student Signature Address: _ Street Home Phone: -- City _ State Zip Code of Birth: //_ Gender: M_, F_ For Participants under the age of eighteen (18) years listed above: I hereby consent and agree to the above as the Parent/Legal Guardian of (minor s name), in which case "I", "me" and "my" as used herein shall refer to said minor. _ Parent or Legal Guardian Name Parent or Guardian Signature 5