West County Lego Robotics
                            Serving 
         Contra Costa, and Alameda Counties
                  in Northern California

After School Registration


After School Registration Form
Please email the following information to: shasta8808@aol.com to register your child for West County Lego Robotics After School Programs.

Attendance:
School District: ____________________________
School: ____________________________
Grade: ___________
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Student:
Child's Name: ____________________________
Child's Age: ________
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Parent or Guardian:
Parent or Guardian: ____________________________
Parent or Guardian: ____________________________
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Pick Up:
Who will be picking up your child?
Parent or Guardian or Authorized Person: ____________________________
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Address:
Street: ____________________________
Apt. ___________
City: ____________________________
State: ____________________________
Zip: ___________
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Special Needs:
Special Needs: ____________________________
Allergies: ____________________________
Medications: ____________________________
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Release:
From time to time, West County Lego Robotics takes Promotional Photographs and video clips of the class for it's website and you tube channel. West County Lego Robotics requests your approval and release to take and use said photographs and video clips during the after school robotics class.  Please fill in the form below to grant your approval and release for West County Lego Robotics to take and use said photographs and video clips for your child during the after school robotics class.

I, ____________________________ Parent/Guardian and ____________________________ Parent/Guardian do hereby grant West County Lego Robotics permission to take photographs and/or video clips of my child ____________________________ during the after school robotics class at ____________________________ School and do hereby approve West County Lego Robotics to use said photographs and/or video clips for use on their website and/or you tube channel.

Signatures:
             ____________________________ Parent and/or Guardian
             Print Name

             ____________________________
             Signature                           Date
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