Lego Robotics Workshop Application

Date of Session Registering for_________________________________________

Student's Name _______________________________________Age ____________

Name of Student's School_______________________________________________

Parent's Name ________________________________________________________

Address _____________________________________________________________

City ________________________________________________________________

Phone _______________________________________________________________

Emergency contact and phone__________________________________________

__________________________________________________________________

e-mail address (only for contacting you for future classes) __________________

____________________________________________________________________

Signature ___________________________________

Date _______________________________________

Mail checks, and make checks payable, to:

Cindy Zimmerman
800 Brommer #88
Santa Cruz, Ca 95062