Senior Retreat Permission Form - Our Lady of Good Counsel High ...

More documents

Recommendations

Info

$IB HL Math Year 2$

SENIOR RETREAT PERMISSION SLIPThe parents/guardians of____________________________ request that he/she(Child’s Name)participate in the Senior Retreat in Sparks, Maryland. We understand that transportationto and from the retreat will be by school bus. Students will leave school at 8AM onMonday and will return to the building on Tuesday around 4:30 PM.The dates for this retreat are: (Please circle one)January 28 – 29, 2013 February 25 – 26, 2013 March 11 – 12, 2013I understand that the rules of Our Lady of Good Counsel High School as stated in theParent/Student Handbook are in effect at all times during the retreat. As aparent/guardian I agree to:1. Release and discharge Our Lady of Good Counsel High School and its employeesfrom any liability resulting from any claims of action for personal injury or medicalexpenses that may arise from school transportation.2. Not hold Our Lady of Good Counsel High School liable for any injurious actionsendured on the part of my son or daughter while he/she is on the retreat.3. Pick up my son or daughter at Msgr. O’Dwyer Retreat House in Sparks, Maryland ifhe or she a) possesses or uses illegal drugs or alcohol; b) is un-chaperoned in an areadesignated for members of the opposite sex; c) crosses York Road without using thepedestrian tunnel; d) trespasses on neighboring property; e) uses a cell phone.__________________________________________________________(Signature of parent/guardian) (Date)PLEASE BE SURE TO FILL OUT THE BACK OF THIS FORM AS WELL.NO STUDENT MAY ATTEND RETREAT WITHOUT BOTH SIDES OF THISSHEET BEING FILLED OUT AND SIGNED BY A PARENT/GUARDIAN.RETURN TO STUDENT’S COMMUNITY OR THE CAMPUS MINISTRYOFFICE.
MEDICAL ATTENTION RELEASE FORMName of Student: _______________________________________ Date: _________________Name of Parents/Guardians: __________________________________________________________Address: __________________________________________________________________________Home Number: _________________________Father: Cell number: _________________________ Work number: __________________________Mother: Cell number: _________________________ Work number: __________________________Insurance Company: _________________________ Policy number: __________________________List all Allergies to food or medicine: ___________________________________________________Reaction: ____________________________________________________________________List any Health Concerns: ____________________________________________________________WRITTEN PERMISSION MUST BE SUBMITTED IN ORDER FOR YOUR SON ORDAUGHTER TO TAKE ANY MEDICATION WHILE ON RETREAT. STUDENTS ARERESPONSIBLE FOR ADMINISTERING THEIR OWN MEDICATIONS.List all Prescription Medications (dosage/frequency) your child will need to take on retreat. Only theexact numbers of pills are to be sent in the original bottle with the physician order on the label____________________________________________________________________________________________________________________________________________________________________List any over the counter medications your child will need to take while on retreat. The medicationmust be sent with the student in the Original Manufacturer’s Bottle.____________________________________________________________________________________________________________________________________________________________________MEDICAL RELEASE FOR TREATMENTI, _______________________________, give permission to any Good Counsel faculty/staff memberto allow medical attention for my child, _________________________, in the event of an emergency.I understand that I will be notified of the incident; however, the faculty/staff member will serve as aconsenting adult in my place.SIGNATURE: ____________________________________ DATE:________________________PLEASE NOTE:NO STUDENT WILL BE ALLOWED TO ATTEND RETREAT WITHOUT THESE FORMSBEING SIGNED AND RETURNED TO THE COMMUNITY MODERATOR.
Page 1: 17301 Old Vic BoulevardOlney, Maryl

Senior Retreat Permission Form - Our Lady of Good Counsel High ...

Create successful ePaper yourself

Delete template?

Save as template?