2015-2016 First Lego League 4-H Club Member Application
Application Form
Team (please circle one): West Harrison School Logan 1 (Goldsmith
Team) Logan 2 (Rose Team) Woodbine 1(Bartels)
Woodbine 2 (Schafer) Woodbine 3(Swenson) 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 2015-2016 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
___Native Hawaiian or Pacific Islander
___or Prefer not to share
___Asian
Residence: ___ Farm (rural area where farm products are sold) ___Suburb of city more than 50,000
___Town under 10,000 and rural non-farm
___Town/City 10,000-50,000 and its suburbs
___Central City more than 50,000
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 ___________________________________
(Agreement must be signed by both youth and their parent/guardian)
Date ____________
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?
___No
___Yes
Are you willing to do research and prepare a presentation that will be given to community leaders on a
project that relates to the 2015 theme “Trash Trek?”
____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 seilstad@iastate.edu or fax to 712/644-2100.