Tech Stars: Robotics -- Complete Registration
PEC Digital Inclusion Presents:
Tech Stars: Robotics
an after school program for students in grades 5-8 interested in programing and electronics.

SPACE IS LIMITED -- Call 267-777-5816
Apply online at
3:30-5pm Mondays - 3939 Warren St

Please complete this form to be considered for acceptance to Tech Stars. If accepted, you may be required to complete other application components including a medical release form, transportation permission slip, media release form, report card release form, behavior agreement, and parent agreement.

Please fill out the info below -- We are updating our records.
Student Information
Student Name *
Your answer
Student Date of Birth *
Your answer
Student Email *
Your answer
Student Home Phone Number *
Your answer
Student Mobile Phone Number *
Your answer
School Information
School Name *
Your answer
Student Grade Level *
Your answer
School Phone Number
Your answer
Teacher or Counselor
Your answer
School for previous school year (if different from above)
Your answer
Parent/Family Information
Parent/Guardian Name *
Your answer
Student Mailing Address *
Please include city, state, and zip code
Your answer
Parent Mobile Number *
Your answer
Parent Email *
Your answer
Survey Information
Although the survey section is all optional, we strongly encourage applicants to provide the information requested. It helps us to report to our funders to continue to provide free programs.
Parent Occupation *
Your answer
Does the student or family own a computer at home? *
What is the condition of the home computer(s)?
Does the family have access to internet at home? *
Student Statement
Please answer the following prompt in complete sentences. This section is to be completed by the student only.
Describe your interests in technology, media, and computers. *
Your answer
Why are you interested in robotics and or programming? *
Your answer
What is your level of experience with these topics? *
I've never done this.
I've done this once or twice
I still need help with this.
I'm pretty good at this.
I'm great at this.
I do this professionally.
Writing Code
Working With Robots
Making Web Pages
Other programming languages
Graphic Design
Any other notes or information we should have about you or your child?
Your answer
Please note: Your child may be included in photographs of program activities used for promotional and other purposes by PEC. PEC is not responsible for Tech Stars students outside the stated hours of the program. Students must be picked up by parents or leave the Families First building at the programs conclusion. *
(Parent) I have read and acknowledge the above statement. My child may be photographed. I will arrange transportation for my child and or they have permission to leave the Families First building unsupervised.
Your answer
parent signature________________________ date_______________
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