Camp Registration – Bot N Brick

Student Information

Name *

First

Last

Students Age

Date of Birth *

Date / Time of Registering *

Date

Time

Used if we have reached our limit and a waiting list is needed.

Name of School *

Grade *

Parent/Guardian Information

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Two Emergency Contacts

Name *

First

Last

Relationship *

Phone *

Name *

First

Last

Relationship *

Phone *

Insurance Information

Health Insurance *

Insurance Provider *

Group Plan # *

Insurance Phone *

Physician *

Physician Phone *

Medical Conditions

*It is your responsibility to inform HLCC Robotics Program (a part of Calvary Church of the Nazarene) of any of the medical conditions that your child may have. This information will be held in confidence and used ONLY to render proper assistance should the need arise.

Does the Student Wear?

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

Describe limitations, medications and history:

Is the student on any medication? *

Yes
No

If so, indicate medication, dosage, condition prescribed for and any known negative drug integrations:

**Note: We do request that if you require medication on a regular basis to monitor a condition that falls within the time that your child is participating in the HLCC Robotics program, that you bring it with you and any instructions necessary.

Does the student have any allergies to food, animals, medications or other (ie bees, peanut butter, aspirin, 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?

**Note: We do request that if you do have anaphylactic allergic reactions that you bring medication to counter it appropriately (ie EpiPen or AnaKit).

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 when your student is partcipating in HLCC Robotics Events?

Lego Camp Registration and Medical Information

Student Information

Parent/Guardian Information

Two Emergency Contacts

Insurance Information

Medical Conditions

Does the Student Wear?

Download Consent Forms