2021-2022 Project Pneuma Registration Form

Does your child have internet and access to a laptop/tablet?YesNo

Allergies/Dietary Restrictions/Medical Concerns/Previous Injuries:YesNo

(Please let us know if you need additional space to provide information)

Is your Child currently receiving any Special Services during the regular school day? Does Your Child have an IEP?YesNo

Parent/Guardian Information:

Child Lives With:Both ParentsMotherFatherOther

Mother's Information

Father's Information

Emergency Contacts

Other persons authorized by the parent to pick up your child. If the parent cannot be reached, the following person maybe contacted in case of illness, injury or emergency. It is the registering parent’s responsibility to keep this list current.

Authorization:

I, , hereby give my son, , authorization to participate in Project Pneuma and all activities. I fully understand that this program has intensive physical, and at times emotional, requirements that will push my son to his limits. I fully understand that my son may incur some bumps and bruises that may result from training/conditioning and he may have some emotional breakdowns/breakthroughs as well. I affirm that I have divulged all information if my son has mental health challenges, physical limitations and/or previous injuries, in which case I release and hold harmless Project Pneuma, the Baltimore City Police Department and Baltimore City Public Schools from any legal action.
Initial:

I, , hereby give Project Pneuma authorization to access my son’s report cards, progress reports and visitation rights (With Proper ID) while my son is in school.
Initial:

I, , understand that my son’s cell phone will be collected at the beginning of session and given back at the end of session.
Initial:

I, , solemnly pledge to be an involved and positive example while my son participates in Project Pneuma. I understand that in order for him to grow and succeed that it will take a holistic approach.
Initial:

I, , give Project Pneuma permission to post pictures of my son on the Project Pneuma website, social media and allow my son to be in print and televised media.
Initial:

I, —Please choose an option—dodo not, give my son, , permission to take the bus home after Project Pneuma session. I release and hold harmless Project Pneuma, the Baltimore City Police Department and Baltimore City Public Schools from any legal action once my son has been dismissed from the Project Pneuma session.
Initial:

Signature:

Date: