Student Information Form projectNINJA projectCHEER Student Name Age DOB Sex M F Grade School Address City State Zip Code Mother's Name Mother's Phone # Father's Name Father's Phone # Preferred Email Insurance Provider Policy # Please list any allergies Are there any medical conditions that we should be aware of? If so, please explain any limitations or restrictions. Emergency Contacts (other than parents): Name Relationship to Child Phone # Name Relationship to Child Phone # How did you hear about us? Photographs and video recordings may be used for publicity or other purposes in print or web-based media outlets. In order to protect our students, please select an option below: I give projectNINJA and/or projectCHEER permission to use my child’s picture in print or web-based media outlets. I do not give projectNINJA and/or projectCHEER permission to use my child’s picture in print or web-based media outlets. Parent Signature Date Send
