ROBOTICS CLUB
Please fill out and return to Mr. Stewart
Please print contact and E-mail information
clearly.
There is a $20 registration fee. This will cover all supplies and the pizza party during the year.
Student’s Name: _____________________________________
Parent or Guardian #1:
Relationship to Student (circle one)
Mom
Name: __________________________________
Other
Telephone (____) _____________
e-mail: ___________________________________________
Parent or Guardian
Dad
Cell phone (
) ____________
#2:
Relationship to Student (circle one)
Mom
Name: ______________________________________
Dad
Other
Telephone (____) ___________
e-mail: ___________________________________________
Cell phone (
)____________
Parent or Guardian Acknowledgement
I (We) are responsible for contacting the main office in an event
of not being able to pick up my child by 4:10pm after the Robotics
club meetings. Please call the school’s main number 571-252-2320
and have a NON-voicemail conversation to let us know of a late
pickup of your child.
How will your child get home (circle an option below) :
Ride the activity bus
_________________________
Parent signature
_________________________
Parent signature
walk
______________
date
______________
date
pick up by parent