EcoRobotik Online Registration

Registration

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Welcome to EcoRobotik! Please complete this form to create an account. We look forward to building with you!

* denotes required fields

Referral Information

How did you hear about us?

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Additional Info

Emergency Contact Name and Phone Number (Not Contact #1 or #2)*

Contact #1

Parent #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

Work #

Cell # *

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Parent #2 First Name

Last Name

Type

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

School

Grade Level

Gender

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

If you'd like to set up your account without enrolling in a class, please scroll down and click Submit Registration.

If you're ready to sign up for a class, click Select Class below.

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

School

Grade Level

Gender

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

If you'd like to set up your account without enrolling in a class, please scroll down and click Submit Registration.

If you're ready to sign up for a class, click Select Class below.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

School

Grade Level

Gender

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

If you'd like to set up your account without enrolling in a class, please scroll down and click Submit Registration.

If you're ready to sign up for a class, click Select Class below.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

School

Grade Level

Gender

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

If you'd like to set up your account without enrolling in a class, please scroll down and click Submit Registration.

If you're ready to sign up for a class, click Select Class below.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

School

Grade Level

Gender

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

If you'd like to set up your account without enrolling in a class, please scroll down and click Submit Registration.

If you're ready to sign up for a class, click Select Class below.

Enroll in Classes

Select Class

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Required Policies

(Show-Hide Details)