Annual Educational Robotics Course Enrollment Formwebsite: www.eaglesnestrobotics.org Email:eaglesnestrobotics@gmail.com Phone: 860-574-5332

1ST CHILD: Name _____________________________________ Sex ____ Age ____ DOB _____/_____/_______2ND CHILD: Name _____________________________________ Sex ____ Age ____ DOB _____/_____/_______3RD CHILD: Name _____________________________________ Sex ____ Age ____ DOB _____/_____/_______Street Address: _____________________________________________ City: _______________ Zip ___________Home Phone: (____)______________________ Email: ___________________@__________________Mom’s Name: ________________________________ Work #: (____)____________ Cell #: (____)____________Dad’s Name: ________________________________ Work #: (____)____________ Cell #: (____)____________ EMERGENCY CONTACT: _________________________________ Relationship to Student: ________________ Emergency #: (____)____________ Circle one: Home - Work - CellHow did you learn about Eaglesnest Robotics? ______________________________________________________________ Does the student(s) have previous experience? Circle One: FIRST LEGO LEAGE Team - Taken a class-Other ___________

This registration packet is due before the first week of class. Please submit these two pages to our email at eaglesnestrobotics@gmail.com

or mail them to the below address.

The 2016/2017 Annual Educational Course has a fixed annual cost which is divided in nine monthly installments of the same amount. Our work dynamics, educational objectives and students projects do not give us the flexibility to allow a split in months or quarters. Initially we require a $35 registration to reserve a place in our classes. A $105 monthly fee is required as monthly tuition and is to be sent to the following Eaglesnest Robotics address.

Eaglesnest Robotics7710 Creekfield Drive

Spring, Tx 77379

Please send this filled out Enrollment form to our email at eaglesnestrobotics@gmail.com or the address above.

Therafter, the monthly payment is due at the beginning of every month beginning September 1, 2016 and is late by the 6th of the month.

**We ask you to set up auto bill pay with your bank by the end of Sept or you will be charged a $15 per month handling fee.*It is VERY important that you contact your bank to set up Auto Bill Pay for class by the end of August.**

The cost of the course is the same for all students regardless of age level the student is attending.

Annual Registration fee: Due upon Initial Enrollment and due every Sept- $36 1st Initial Students - $30 Sibling Student

The Breakdown of Initial and monthly tuition is as follows:

September 15th $105 + $35 Annual Registration fee= $140 (Initial Registration done on EventBrite Registration page). October 5th-$105November 5th-$105December 5th-$105January 5th- $105February 5th- $105March 5th- $105April 5th- $105

Tuition (Sibling Discount is 20% of Initial students tuition) $______Sibling (1) tuition $_______ Sibling(2) tuition $ _______ Sibling(3) tuition Family Tuition Total: $____________

WAIVER OF LIABILITY • PHOTO RELEASE • MEDICAL AUTHORIZATION

In consideration for my or my child(ren)’s participation I hereby, for myself and my child(ren) and our respective heirs and successors, PROMISE NOT TO SUE and FOREVER RELEASE EAGLESNEST ROBOTICS, its officers, directors, shareholders, employees, contractors and volunteers from all liability resulting in damages or injuries incurred as a result of participation.

I am aware that individual and group publicity photos and videos are taken from time to time and in consideration for my or my child(ren)’s participation I hereby grant my permission for my child’s likeness to be used in EAGLESNEST ROBOTICS publicity or advertising.

In the event of an accident or emergency I hereby authorize my child(ren) to be transported to a hospital for medical treatment and I hold EAGLESNEST ROBOTICS and it’s representatives harmless in the execution of such. Additionally, I hereby agree to individually provide for all medical expenses which may be incurred by myself or my child(ren) as a result of any injury sustained while participating at or for EAGLENEST ROBOTICS.

I have read and understand this ASSUMPTION OF RISK and WAIVER OF LIABILITY and PHOTO RELEASE and MEDICAL AUTHORIZATION and I VOLUNTARILY affix my name in agreement. PARENT/LEGAL GUARDIAN’s signature _________________________________________________Date __________

DISCOUNTS:Returning students-receive a discounted rate of $10 off next years monthly tuition rate per month. Sibling Discount-Sibling student discount is 20% off the Initial student's tuition. Late Fees- Monthly tuition is due by the 6 th day of the month and a $10 late fee is applied to account. The student will be dropped from the class after a 3 day grace period unless cleared.Cancellation policy-Registration will not be refunded. If you are withdrawing your child after the first day of the course, a financial penalty will be applied to cover the charge of the consumable curriculum as well as an additional month of tuition. Exceptions will be applied in the cases of the following: serious illness or death in the immediate family, loss of one’s job, or an unexpectedmove. Please do not register for the Educational Robotics Course knowing you will not be able to complete the school year.I understand and agree to the conditions of payments, late fees, and cancellation policy listed above. _______________________________________________ ___________________Signature DateRegistration is not complete until Registration fee of $35 per student has been turned in along with this enrollment form.

Office Use Only Information

Class & Payment Enrollment Date:________________1st Child 1st class Date:____________Time:_________2nd Child 1st class Date:________ ___Time:_________3rd Child 1st class Date:____________Time:_________

Annual Registration fee: (Sept to July - Prorate Mar to Apr)

$35 1st Child - $30 Siblings. Total $______________