FLL Robotics, AOMS Team 1 (2020-21)

Student Information

Student's Name*

First Last

Gender

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Other

Grade Level Entering Fall 2020*

School Student Will Attend Fall 2020*

Parent/Guardian Information

Guardian Name*

First Last

Guardian Email*

Guardian Phone Number*

Relationship to Student*

Guardian Address*

Street Address Address Line 2 City State ZIP Code

Employer*

Matching Gifts

Please check box if your employer provides matching gifts for donations.

YES! My employer provides matching gifts

Emergency Contact Name*

First Last

Emergency Contact Phone Number*

Acknowledgement of Policies and Consent

Liability and Photographic Release

I agree to indemnify and hold harmless the Carlsbad Educational Foundation (CEF) and the Carlsbad Unified School District and their officers, agents, or employees from any liability claim or action resulting from or in any way rising out of the participation in this activity by the registered person.

Liability*

I agree

I also permit CEF to use and publish photographs and/or video of my child for the purpose of promoting robotics and the work of the Carlsbad Educational Foundation.

Photo Release*

Give Consent
Do not Give Consent

In the event that my child experiences a severe, life-threatening anaphylactic (allergic) reaction during a CEF program, I...*

Give Consent
Do not Give Consent

for a trained/designated school staff member to administer the EpiPen emergency treatment, under indirect supervision of the school nurse. In the event the parent/guardian cannot be reached, permission is hereby given for the physician designated below to provide emergency care for my child should serious illness/injury occur at a FLL practice or event.

Physician Name*

Physician Phone*

Preferred Hospital*

ARE THERE ANY HEALTH PROBLEMS OR OTHER PERTINENT INFORMATION THAT WOULD BE BENEFICIAL TO YOUR CHILD'S EXPERIENCE TO SHARE WITH US? SOME EXAMPLES MIGHT BE ALLERGIES (WITH TREATMENT), PHYSICAL OR LEARNING DISABILITIES, SPECIAL EDUCATION NEEDS OR IEP'S. OR INDICATE "NONE":*

If applicable:

Carries Inhaler
Carries EpiPen

As legal custodian of*

minor/student, I hereby authorize the principal or his/her designee, into whose care the aforementioned minor student has been entrusted, to consent to any X-ray, examination, anesthetic, medical or surgical diagnosis, treatment and/or hospital care to be rendered to said minor/student upon the advice of any licensed physician and/or dentist. I understand that this authorization is given in advance of any required diagnosis, treatment, or hospital care and provides authority and power to the aforementioned agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which a licensed physician or dentist may deem necessary. This authorization shall remain effective for the full robotics program unless revoked in writing and delivered to said agent(s). I understand that CEF, its employees and its Board assume no liability of any nature in relation to the transportation or treatment of the said minor/student. I further understand that all costs of paramedic transportation, hospitalization and any examination, X-ray or treatment provided in relation to this authorization shall be my responsibility.

Person(s) assuming financial responsibility*

By typing my name below, I certify that the information provided is correct, and provide the permissions to treat as indicated above.*

Date*

Comments

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FIRST LEGO League Robotics Registration Team 1 - 2020-21

Student Information

Parent/Guardian Information

Acknowledgement of Policies and Consent

Liability and Photographic Release