PART #2 - ADDENDUM TO ONLINE ORTOP FLL SCHOLARSHIP APPLICATION FOR GORGE AREA PUBLIC SCHOOLS
ORTOP FLL Scholarship – Individual Team Information

PLEASE READ CAREFULLY and TYPE IN OR PRINT IN LEGIBLE HANDWRITING FROM THIS POINT FORWARD.
Your scholarship depends on it.

Scholarship Applicant name must match the name on the online form submitted. This is the only way we can match up the information.

1)ORTOP FLL Scholarship Applicant______

2)SCHOOL or ORGANIZATION AFFILIATION______

3)How many FIRST LEGO League Team scholarships are you requesting funding at this one school or organization location? (needs to match online form)

______# of Team Scholarships requested.

Definitions of Returning and New Teams

Returning team - team with access to a Mindstorm Robot Kit previous awarded to the school/organization even if there are all new students on the teams.
New Team - team without a Mindstorm robot kit applying for a scholarship for the first time or an additional team at an school/organization who does not have access to a Mindstorm Robot Kit.

For each team you are requesting funding please provide the following information.

SECTIONS TO COMPLETE
A) Scholarship Status B) Coach Information C) Team Profile D) Team Success Plan E) Team Scholarship Request

To the best of my knowledge, I certify that all of the information provided is correct and true.

______

Scholarship Applicant signature Date Email Address

Submit completed for

By email to

PLEASE USE SUBJECT LINE: FLL Scholarship Part #2 – GORGE
or

FAX TO 503-725-2921

or

Mail to: ORTOP

PO BOX 751, IAFF
Portland, OR 97207-0751

Round One Deadline is June 30, 2013. If funds remain, Round Two will be announced on the ORTOP website.

A)Scholarship STATUS
Team # 1 / Team #2 / Team #3
Returning or New Team? / TEAM: Returning or New / TEAM: Returning or New / TEAM: Returning or New
B)Coach Information
Team # 1 / Team #2 / Team #3
COACH NAME
COACH EMAIL
New or returning Coach? / Coach: New or Returning / Coach: New or Returning / Coach: New or Returning
Attended Training / YES or No / YES or No / YES or No
If No, Registered to Attend? / YES or No / YES or No / YES or No
C)Team Profile
Team # 1 / Team #2 / Team #3
Grades of Students on Team
Total # of students must be no less than 6 and no more than 10.
# of Boys
# of Girls
# of Underrepresented Students*
*ORTOP encourages teams to be inclusive of students from communities who are underrepresented in engineering and computer science related industries. Please estimate the number of students on your team who are Black/African American, Latino/ Hispanic and/or American Indian/Alaskan Native
Accurate or Estimated profile of team /
Accurate or Estimated
/ Accurate or Estimated / Accurate or Estimated
Does this team have a Mindstorm Robot kit to use the FLL season either owned by the school/organization or awarded in a prior year by an ORTOP FLL scholarship? / Yes No / Yes No / Yes No
Name of School(s) attended by students
D)TEAM SUCCESS PLAN
Team # 1 / Team #2 / Team #3
STATE where team meets / OREGON or WASHINGTON / OREGON or WASHINGTON / OREGON or WASHINGTON
COUNTY where team meets (not country)
CITY where team meets
Is this an Urban, Suburban or Rural location? / Urban / Suburban / Rural / Urban / Suburban / Rural / Urban / Suburban / Rural
Where will your team meet? Please describe the location where the team will meet (classroom, school cafeteria, church basement, a home, community center, etc.).
When will the team meet; during school, after-school, evenings, weekends?
Start date for team meetings?
Duration of each team meeting? 1.0 hours, 1.5 hours, 2 hours, etc).
How often do you anticipate the team can meet (weekly, twice a week, three times, etc)
Will the team meet semi-regularly during the off-season? How often?
E)TEAM FIRST LEGO LEAGUE SCHOLARSHIP REQUEST
Team # 1 / Team #2 / Team #3
1)For each team check the items you are requesting as part of your scholarship. Do not include items already owned by your team or items your team can afford to purchase on their own via fundraising or other donations.
2)Returning Teamsshould not request a robot. ORTOP cannot afford to purchase new EV3 robots for schools/organizations already in the scholarship program. (at least not this year).
National FLL Registration - $240 / ____National FLL Registration / ____National FLL Registration / ____National FLL Registration
Nature’s Fury Field Set-up kit (FSK)- $80* / ___ FSK / __FSK or ___team will share / __FSK or ___team will share
*if teams practice at the same location, teams are encouraged to share a Field Set-up Kit. Only request one FSK per 3 teams if practicing in same location.
FOR NEW TEAMS ONLY: Mindstorm Robot Kit / FOR NEW TEAMS ONLY
_____NXT KIT or _____EV3 KIT / FOR NEW TEAMS ONLY
_____NXT KIT or _____EV3 KIT / FOR NEW TEAMS ONLY
_____NXT KIT or _____EV3 KIT
ORTOP Qualifying Tournament Fee - $75 / ___ORTOP QT Fee / ___ORTOP QT Fee / ___ORTOP QT Fee
Amount of team funds from other sources that can be used to offset FLL registration and equipment costs. / $______/ $______/ $______