Umoja Robotics Application 2024-2025

ACCN is thrilled to invite you to join the Umoja Robotics Team for the 2024/2025 season. This is your chance to be part of an exhilarating experience that goes beyond building a robot.

Student Details

Student's Name *

First

Last

Email *

Email

Confirm Email

Date of Birth *

Student's Phone

Student's Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Grade in September 2024 *

• Grade 8
• Grade 9
• Grade 10
• Grade 11
• Grade 12
• Other

Are you a returning student? *

• Yes
• No

ACCN Program(s) you were/are enrolled in: *

• NPHP Youth
• Intro to Coding
• Web Development
• Coding II | Advanced
• CAD | Computer Aided Design
• None of the above

Do you have any experience with Robots/Robotics? *

• Yes
• No

Briefly describe your experience. *

Do you have experience in any area listed below? *

• Coding/Programming
• CAD (Computer Aided Design)
• Animation
• Photography/Video Editing
• Public Speaking
• Creating Presentations
• Comfortable using tools
• Social media content creation
• None of the above

Parent Details

Parent's Name *

First

Last

Parent's Email *

Email

Confirm Email

Relation to Student *

• Mother
• Father
• Guardian

Register another Parent *

• Yes
• No

Parent's Name #2 *

First

Last

Parent #2 Email *

Email

Confirm Email

Relation to Student *

• Mother
• Father
• Guardian

I/We want my/our child to be part of ACCN Robotics Team because: *

Read our Student Code of Conduct

Code of Conduct

Read our Parental Consent and Release

Parental Consent and Release

If my/our child is selected for ACCN’s UMOJA ROBOTICS program, I/we agree that: *

• I/we will be committed to supporting the success of my child and the team
• I/we will ensure that my child abides by the ACCN’s Code of Conduct
• I/we will contact ACCN about any concerns regarding my child in the program

Declaration *

• By checking the box, I acknowledge that I have read the foregoing Code of Conduct and Parent Consent & Release Form and understand its contents, and I voluntarily agree and consent to all terms and conditions noted in this Form. This consent and release will remain effective for the duration of my child's enrollment in the ACCN program and until my child turns age eighteen. By typing or signing my name below, as the parent/guardian of the ACCN registrant, I am electronically signing this consent form.

Name of Parent/Guardian *

Date *

Submit