UNIVERSAL POWER CHEER DEL RIO, TEXAS STUDENT INFORMATION: NAME_________________________________________________       AGE________ ADDRESS_________________________________DATE OF BIRTH_____________ CITY, STATE, ZIP______________________________________________________ NAME OF PARENT OR GUARDIAN_______________________________________ HOME PHONE_____________________          CELL PHONE___________________ WORK PHONE_____________________ IN CASE OF AN EMERGENCY CONTANT (PLEASE PRINT) 1) NAME_____________________________________________ RELATION TO STUDENT ______________________________ HOME PHONE_____________________          CELL PHONE___________________ WORK PHONE_____________________ 2) NAME_____________________________________________ RELATION TO STUDENT ______________________________ HOME PHONE_____________________          CELL PHONE___________________ WORK PHONE_____________________

Are you allergic to any medications?             Yes     No If so, please list _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Psysician Name ________________________________________ Psysician Phone ________________________________________ I,_______________________________________(Parent/Guardian) understand that Universal Power Cheer is not responsible for any major injuries that may happen to my son/daughter,______________________________. Universal Power Cheer is allowed to call 911 or contact the emergency contact listed above incase I cannot be reached. _______________________________________                        ______________                   Parent/Guardian Signature                                                        Date