Project Pneuma Student Registration Form
Student Information
Student First Name (Required)::
Student Last Name (Required)::
Student's Full Address (Required)::
Gender (Required)::
Female
Male
I describe my gender differently I prefer not to a
I prefer not to answer
Grade (2023-2024) (Required)::
4
5
6
7
8
9
School (Required)::
Baltimore Design School
Calvin Rodwell
Commodore John Rogers
Cross Country Elementary/Middle
Empowerment Academy
Green Street Academy
Mary Ann Winterling
Park Heights Academy
Other
Katherine Johnson
School Name (If not listed above)::
Student ID Number:
If Yes Please Provide Details:
Parent / Legal Guardian Information
Primary point of contact (Required):
Primary Guardian Contact Information
Primary Legal Guardian Relationship (Required):
Mother
Father
Grandparents
Other Guardian
Primary Legal Guardian Name (Required):
Primary Legal Guardian Email (Required):
Primary Legal Guardian Cell Phone (Required):
Primary Legal Guardian Work Phone:
Primary Legal Guardian Home Phone:
Primary Legal Guardian Full Address (Required):
Secondary Guardian Contact Information
Secondary Legal Guardian Relationship:
Mother
Father
Grandparents
Other Guardian
Secondary Legal Guardian Name:
Secondary Legal Guardian Email:
Secondary Legal Guardian Cell Phone:
Secondary Legal Guardian Work Phone:
Secondary Legal Guardian Home Phone:
Secondary Legal Guardian Full Address:
Emergency Contact Information
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.
Emergency Contact #1
Emergency Contact Name (Required):
Emergency Contact Relationship (Required):
Emergency Contact Phone Number (Required):
Emergency Contact #2
Emergency Contact Name (Required):
Emergency Contact Relationship (Required):
Emergency Contact Phone Number (Required):
Emergency Contact #3
Emergency Contact Name:
Emergency Contact Relationship:
Emergency Contact Phone Number:
Authorizations
I hereby give my child authorization to participate in Project Pneuma programming and all activities. I fully understand that this program has intensive physical, and at times emotional, requirements that will push my child to their limits. I fully understand that my child may incur some bumps and bruises that may result from training/conditioning and they may have some emotional breakdowns/breakthroughs as well. I affirm that I have divulged all information if my child has mental health challenges, physical limitations and/or previous injuries, in which case I release and hold harmless Project Pneuma and Baltimore City Public Schools from any legal action.
I give Project Pneuma authorization to access my sons report cards, progress reports, and visitation rights (with proper ID) while my son is in school.
I understand that my child's cell phone will be collected at the beginning of session and given back at the end of session.
I solemnly pledge to be an involved and positive example while my child participates in Project Pneuma. I understand that in order for them to grow and succeed that it will take a holistic approach.
I give Project Pneuma permission to post pictures of my child on the Project Pneuma website, social media and allow my child to be in print, social media and televised media.
I do / do not give my child permission to take alternative transportation if they do not utilize transportation provided by Project Pneuma.
I release and hold harmless Project Pneuma, the Baltimore City Police Department, and Baltimore City Public Schools from any legal action pertaining to transportation provided by Project Pneuma.
Project Pneuma reserves the right to remove your child from the program immediately if they, or a parent, displays actions that may be detrimental to the health and/or wellbeing of another participant, team member, volunteer or teacher. This includes witholding pertinent information that may put your child or others at risk.
Name/Signature of Person Completing This Form (Required):
Email Address (Required):
Relationship to Student (Required):
