Registration Form:

Teacher/coach Workshops

Name: ____________________________________

Email: ____________________________________

School/organization: ___________________________________

Address: _____________________________________________

City: ____________________

State: ___________________

Zip Code: _______________

Work Phone: ___________________

Alternative Phone: __________________

Program:

(check on-line schedule for availability and full/open status of these programs.  Call or email if you have questions)

[   ]       Introduction to LEGO Robotics and Robolab                                                               $80

[   ]       Advanced Programming in  RoboLab                                                                           $80

[   ]       Introduction to RoboLab Investigator                                                                           $80

Location: __________________________________

Date of workshop: _______________

Payment method:

[  ] check (enclosed)     Check No._______                                         Amount of Payment: ________

[  ] Visa  [  ] Mastercard                                                                       Purchase Order No: ____________

PO Source (i.e. school name)

Name on card _____________________

____________________________

Card number _____-_____-_____-_____

Expiration date: _____/_____                                                   Send to:  Maine Robotics

167 Bennoch Road

Signature: _________________________                                             Orono, ME 04473

Or to: bickford@mainerobotics.org