Mentor Volunteer Registration Form - Badgerbots
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1
2Mentor/Volunteer Registration Form
Consent, Release, Hold Harmless, and
Authorization to Reproduce Physical Likeness
Complete information below (please print legibly).
Date:
MENTOR/VOLUNTEER INFORMATION
BADGERBOTS
FTC
FRC
SUMMER DAY CAMP
Minor League
FLL
PROGRAM:
DOB:
GENDER:
MENTOR/VOLUNTEER NAME:
Male
Female
COMPANY OR SCHOOL ATTENDING:
COMPANY OR SCHOOL ADDRESS:
HOME PHONE:
CELL PHONE:
WORK PHONE (OPTIONAL)
OTHER PHONE:
(
)
(
)
(
)
(
)
PRIMARY EMAIL ADDRESS:
SECONDARY EMAIL ADDRESS (OPTIONAL):
ADDRESS:
CITY:
STATE:
ZIPCODE:
PERSON TO CONTACT IN CASE OF EMERGENCY:
RELATIONSHIP:
CELL PHONE:
HOME PHONE:
(
)
(
)
ADDITIONAL EMERGENCY CONTACT INFORMATION (Optional)
EMERGENCY CONTACT #1:
RELATIONSHIP:
CELL/HOME PHONE: (
)
WORK PHONE: (
)
EMERGENCY CONTACT #2:
RELATIONSHIP:
CELL/HOME PHONE: (
)
WORK PHONE: (
)
MEDICATION / MEDICAL CONDITION
Please describe medications and medical conditions ONLY if they affect your safety or the appropriate medical treatment should an
injury or illness occur.
MEDICINE:
WHEN IS IT ADMINISTERED:
DOSAGE:
MEDICINE:
WHEN IS IT ADMINISTERED:
DOSAGE:
MEDICATION CONDITION :
SYMPTOMS:
APPROPRIATE RESPONSE:
ALLERGIES (FOOD OR OTHER):
Your signature grants BadgerBOTS Robotics Corporation and its agents the right to authorize emergency medical treatment to you if you are unable to
provide consent yourself at the time.
____Initials
T-SHIRT SIZE (CHOOSE ONE BELOW)
Youth S
Youth M
Youth L
Adult S
Adult M
Adult L
Adult XL
Adult XXL
Adult XXXL
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