TechBrickEducationLogoFull v01 01 300  Registration and Information

Registration TechBrick Education for Mentors
  1. **********************************************************************************
    We need all mentors, even if you have mentored in the past, to complete this form.
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    Please choose your primary program and status and complete the form below.

  2. What is the primary program you would like to support(*)




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  3. Other Programs You'd Like to Support




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    Select all programs in which you have interest.
  4. Enrollment Status(*)


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  5. *************************************************************************
    MENTOR INFO
  6. First Name
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  7. Last Name
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  8. Email
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  9. Cell Phone
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  10. Gender

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  11. Mentor Birthday
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    Please enter the date in mm/dd/yyyy format.
  12. Shirt Size
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  13. *************************************************************************
    MENTOR EMPLOYER
  14. Mentor Employer
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  15. Job Title
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  16. Advanced Degrees
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  17. What does your work involve?
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  18. Employer Website
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  19. Does Your Employer Fund STEM Education

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  20. *************************************************************************
    HOME ADDRESS
  21. Address 1
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  22. Address 2
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  23. City
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  24. State
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  25. Zip
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  26. *************************************************************************
    NON PARTICIPATING DAYS
    This is based on personal or religious preferences and DOES NOT include conflicts with other activities.
  27. Please indicate days you cannot participate in practice or events.







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  28. *************************************************************************
    YOUTH PROTECTION

    US FIRST and TechBrick are participating in a comprehensive Youth Protection Program. As a parent of a student in our program you will be asked to review basic youth protection training (no more than 45 minutes) and apply for a basic background check (no fee). For more information see: CLICK HERE FOR MORE INFO

    I agree to participate in this program as a pre-requisite for my participation.
  29. Signature
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    Enter your name between the slashes.
  30. *************************************************************************
    INJURY TRAVEL WAIVER

    I authorize TechBrick Robotics and its mentors and leaders to supervise my child/children from and provide transportation to various events and functions. Further, I authorize emergency medical decisions to be made on my behalf if the authorized emergency contacts cannot be reached. Participant (and the Parent/Guardian of a Participant under 18 years of age) understands that participation in the Program will expose Participant to risks of injury including, without limitation, injury from: building, lifting, and using electrical/mechanical robots and robot components; using tools; other participants; dancing and other associated activities. Participant, if 18 years of age or older, acknowledges and agrees that he/she is primarily responsible for his/her safety. The Parent/Guardian of a Participant under 18 years of age acknowledges and agrees that the Parent/Guardian is primarily responsible for the Participant's safety and that the Parent/Guardian will monitor, as appropriate considering the age of the Participant and other factors, the Participant's participation in the Program. In consideration for TechBrick allowing the Participant to participate in a Program, Participant (and the Parent/Guardian of a Participant under 18 years of age for and on behalf of the Participant and the Parent/Guardian) assumes all risk of such participation and hereby releases TechBrick and (except as expressly provided below) all of TechBrick's directors, officers, employees, volunteers, and agents from any and all claims for any injury of any kind to the Participant (and the Parent/Guardian) or other damages that may occur as a result of the Participant's participation in the Program, including without limitation any injuries or other damages that may be caused by the negligence of TechBrick or negligence of any of TechBrick's directors, officers, employees, volunteers, or agents (including without limitation negligently failing to adequately investigate or screen coaches, mentors, volunteers, etc.), and agrees not to file any lawsuit or otherwise make any claim against TechBrick or any of TechBrick's directors, officers, employees, volunteers, or agents for any such injury or other damages. The Participant (and the Parent/Guardian of a Participant under 18 years of age) does not hereby release any claims against any individual person who intentionally causes injury to the Participant.
  31. Signature
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    Enter your name between the slashes.
  32. Waiver Date
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    Please enter the date in mm/dd/yyyy format.
  33. *************************************************************************
    ACKNOWLEDGEMENT OF ADDITIONAL FEES
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    Some events, particularly those including travel, may require additional fees beyond the dues. This is particularly true for the World Championships. Local events may incur food costs and minor travel expenses. These amount vary depending on the event and the level of fund raising.

    We acknowledge that there may be additional events and fees throughout the year which we may choose to participate in or not based on our student’s schedule.
  34. Signature
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    Enter your name between the slashes.
  35. *************************************************************************
    CITIZENSHIP
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    We have to make special arrangements for foreign nationals. Please indicate your US citizenship status. If you are not a United States citizen please enter your country of citizenship.
  36. Are you a United States Citizen
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  37. If you are not a US citizen, please enter your country of citizenship.
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  38. *************************************************************************