2014-2015 Jr FIRST Lego League 4-H Club Member Application
Application Form
Team:
Harrison County Extension Office
1) Contact Information :
Name________________________________ Age ________ Gender M _____ F _____
First
MI
Last
Address_____________________________________Town________________Zip___________
Home Phone_________________________Email_____________________________________
Parent Cell Phone _______________ School __________________Birthdate _______________
mm/dd/yyyy
Parent(s)/Guardian(s)____________________________________________________________
Grade 2014-2015 school year _______________
2) Your Interests and Abilities:
1) Briefly describe your interest in being a member of a 4-H Jr 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 a team project?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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 Jr FIRST Lego League
Club?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
5) What experiences have you had in building things?
___________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
6) Are you willing to commit 2 hours every other week between February and March to work with your
team in learning the basics in Lego Robotics Programming and building and to complete the tasks
required in the Jr. 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?
___No
___Yes
Are you willing to do research and prepare a presentation on a project that relates to the 2015 theme
Think Tank “Redefining Learning” taking a look at where and how learning happens every day?
____Yes
___No
Are you open to using communication techniques such as email, instant messaging and computer
conferencing?
___Yes
___No
3) Required Recommendations:
a) You must have a parent/guardian fill out and sign the parent/guardian
recommendation form.
4) Required Medical Information Release Form:
a) You must have a parent/guardian fill out and sign the Medical
Information Release form.
Return this completed form, the parent recommendation form and the Medical Information
Release to the Harrison County Extension Office, 304 East 7th Street, Logan, IA 51546. You can
email the application as an attachment to seilstad@iastate.edu or fax to 712/644-2100.