Robotics Club

Christopher Columbus High School/Starbot, Inc.

3000 S.W 87th Avenue, Miami, Florida 33165

Application for Membership (Part I)

Please print clearly!
Todays Date______________________

_______
New Member.
List Robotics Experience, if any:
__________________________________________________________________
_______

Returning Member. Years in Robotics Club: ____

Student Name___________________________________________________
ID# ____________
Grade: __________
Homeroom: __________
Birth Date: ______________
Address: __________________________________________________________________
City _____________________
Zip Code: ___________
E-mail Address: _________________________________________________________
Home Phone: _________________________Cell Phone: _______________________
Shirt Size: Adult S_____M______L_____XL_____XXL______
Parents/ guardians information:
Mothers Last Name: _______________________________ First Name: ___________________________
Address if different from student: ___________________________________________________________
City:______________________ Zip Code: __________
Home phone: __________________
Email Address: __________________________________________ Cell Phone:____________________
Employment:____________________________________________ Work Phone:___________________
Fathers Last Name: ______________________________ First Name: _____________________________
Address if different from student: ____________________________________________________________
City:______________________ Zip Code: __________
Home phone:___________________
Email Address: _________________________________________
Cell Phone:_____________________
Employment:___________________________________________
Work Phone:____________________
Emergency Contact:
Name:________________________________________________
Relationship: ____________________
Home phone: __________________________________________
Cell phone: _____________________
Doctor: ______________________________________________
Business Phone: __________________
Medical Problems/Conditions/Allergies:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Please list all classes you are taking this year, including any you may be taking outside of school:
____________________________________________________________________________________________
____________________________________________________________________________________________
List all clubs and extra-curricular activities
____________________________________________________________________________________________

2012-13 Starbot Fees:

___________
___________

$600 for new members.

$400 for returning members.

Enclosed is check#____________
Enclosed is check #___________

I will be able to meet my financial obligations to the Club.

I would like to request a meeting to discuss my options for payment.

Fees are payable to Christopher Columbus High School Please write CCHS Robotics Club in the Memo
section. These fees are strictly used to pay Starbot, Inc. for classes and shop fees. They DO NOT cover materials
for building a robot, components, travel and travel related expenses and incidentals. Deadline: October 1st .

Students are encouraged to seek sponsorships to cover their shop fees and robot building expenses. All checks
collected from Sponsors, should be made payable to CCHS (Robotics Club written in the Memo section) If a
student would like for their sponsorship money to cover their Starbot fees, a check for the difference between the
Sponsorship money and the amount of Starbot fees paid will be written as reimbursement. All money raised above
the shop fees will be applied to the CCHS Robotics Club. This money could be used to pay for the members travel
expenses and/or team expenses, as needed. Parents donations to the club over the amount of Starbot fees will be
applied to the corresponding level of sponsorship (see sponsorship form) and will cover members travel or team
expenses, as specified. Please write members name and ID # on all sponsorship forms at the bottom so the student
gets credit.

_______

I am enclosing a gift of $_________ to help with the materials and other costs of the CCHS
Robotics program, as needed.

_______

My Company will match my gift. Please contact ____________________________________.

_______

I am interested in becoming a sponsor of the Robotics Club. Please fill out Sponsorship Form.

I understand that in order to continue participating in the Columbus Robotics Club, I must
remain academically in good standing and I must dedicate the time necessary for the
teams success. I must abide by the school code as outlined in the student handbook and by
the rules and regulations of Starbot, Inc. If I fail to do so, I understand that after 3
warnings I may be expelled from the team without any refunds.

________________________________________________________________
Student's Signature

__________________
Date

I have read the above information and I understand these responsibilities pertinent to the CCHS Robotics Club.

________________________________________________________________
Parents/Guardians Signature

______________
Date

Please return this completed form and payment to Mr. Alexis Ibarras room C-23 by October 1st.

Note that no student will be allowed to participate in any Robotics Club activities, classes
or shop until registration is complete (Part I and Part II).