Application Form s17

2016-2017 First Lego League 4-H Club Member Application

Application Form Team (please circle one): West Harrison School Logan 1 (Goldsmith Team) Logan 2 Woodbine Team Missouri Valley

1) Contact Information :

Name______Age on August 1______Gender M_____F____ First MI Last Address______Town______Zip______Family Phone______Email______

Parent Cell Phone 1______School ______Birthdate ______Parent Cell Phone 2 ______mm/dd/yyyy Parent(s)/Guardian(s) #1______#2______First Name Last Name First Name Last Name Grade 2016-2017 school year ______

Emergency Contact ______Phone # ______Relationship ______

Ethnicity Are you of Hispanic ethnicity ___No ___Yes (please indicate both an ethnicity and race) RACE: ___White ___Black ___American Indian or Alaskan Native ___Asian ___Native Hawaiian or Pacific Islander ___or Prefer not to share

Residence: ___ Farm (rural area where farm products are sold) ___Suburb of city more than 50,000 ___Town under 10,000 and rural non-farm ___Central City more than 50,000 ___Town/City 10,000-50,000 and its suburbs

4-H Behavior Expectations Agreement: As a 4-H Member: It is important to follow the directions of the 4-H Robotics Club Leader at all times. As a 4-H Member and guardian: I understand that as a participant and/or guardian I have the responsibility to help make all 4-H Activities a safe experience for everyone through my behavior and conduct. I also understand the importance of following rules, directions, and policies and agree to follow them.

4-H Robotics Club Member Signature ______Date ______

Parent/Guardian Signature ______Date ______

(Agreement must be signed by both youth and their parent/guardian)

2) Your Interests and Abilities: 1) Briefly describe your interest in being a member of a 4-H First Lego League Club:

______

2) Please list/tell us about your interests, hobbies, and talents. Have you ever been part of a school project or participated in science fairs or projects?

______

3) Briefly describe the good things you bring to a team from your past experiences as a part of a team in school or in another youth organization or sport: ______

______

4) What do you hope to get or learn from being a member of the 4-H First Lego League Club? ______

______

5) What experiences have you had in building things?

______

6) Are you willing to commit 3-4 hours per week between September and December to work with your team in learning and programming your Lego Mindstorm Robot to complete the tasks required in the First Lego League Challenge? ___Yes ___No Are you willing to share ideas and listen to the ideas of others? ___Yes ___No

Are you committed to gathering input from others? ___Yes ___No

Are you willing to do research and prepare a presentation that will be given to community leaders on a project that relates to the 2016 theme “Animal Allies?” ____Yes ___No

Are you open to using communication techniques such as email, instant messaging and computer conferencing? ___Yes ___No 3) Required Recommendations: You must have a parent/guardian fill out and sign the parent/guardian recommendation form.

Return this completed form and the parent/guardian form to your coach or the Harrison County Extension Office, 304 East 7th Street, Logan, IA 51546. You can email the application as an attachment to [email protected] or fax to 712/644-2100.