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Kellogg Community College Bruin Bots

Middle School Robotics Club - REGISTRATION FORM

1. Contact Information:
STUDENT NAME ___________________________________________________________________
DATE OF BIRTH _____________ GRADE ______ SCHOOL __________________________________
ADDRESS _________________________________________________________________________

CITY/STATE/ZIP ____________________________________________________________________
PARENT / GUARDIAN EMAIL __________________________________________________________
EMERGENCY CONTACT 1 ____________________________________________________________
PHONE 1 ________________________

PHONE 2 ____________________________

EMERGENCY CONTACT 2 ____________________________________________________________

PHONE 1 _________________________

PHONE 2 ____________________________

2. Meeting Schedule: Bruin Bots club meetings will occur at the RMTC at the following times:

Tuesday and Thursday from 4:00pm to 5:30pm

Thursday, February 6th , 2014 through Thursday, May 15th, 2014

Club members should try to be present at all meetings. If for some reason a team
member must be absent it would be helpful to note those dates now for planning purposes. Please
indicate any days you know your student will be absent below:
If for some reason a team member must be unexpectedly absent from practice, please contact
Kimberlee Andrews-Bingham at 269-565-2802 or and leave a message.

Please complete and return to:

Regional Manufacturing Technology Center, 405 Hill Brady Rd, Battle Creek, MI 49037
or Fax to: 269.962.7370

Registration will not be complete until this form is returned.

4. Release and Waiver of Liability - Please read carefully before signing.

The undersigning hereby acknowledges that participation in this program and
related activities involves an inherent risk of physical injury, and the undersigned,
on behalf of the registrant, hereby assumes all such risk and does hereby release
and forever discharge the program and the college, and all employees and agents
thereof from any and all liability of whatever kind of nature, arising from and by
reason of any and all known and unknown injuries, damage to property, and the
consequences thereof, resulting from the registrants participation in or involvement with this program, including failure of equipment or defect in premises.
Childs Name _________________________________________________________
I hereby state that I am the legal guardian of said child and agree to the above


Printed Name


5. Photo Release: I authorize KCC to use images, videos and audio of my child (or minor for
which I am legally responsible) captured during college sponsored activities for use in promotion, publications and materials. I understand that all images, videos and audio will solely be
used for college purposes and that I will not be compensated for my image, voice or comments.
I also understand that KCC owns all images and recordings.
Minor childs name:


Parent / Legal Guardian:


Please note students

should not bring any
Lego or building
materials to practice.