Retreats: Sophomore Girls 23-24

Campus Ministry

2023-24 Sophomore Girls Retreat Permission

Sophomore Girls Retreat will take place at St. Benedict Inn, Indianapolis.

Student First Name:*

Student Last Name:*

Retreat Date*

September 21-22, 2023April 25-26, 2024

Not sure which retreat your student is scheduled for? View Rosters Here

Parent/Guardian#1:*

Relationship to student*

Emergency Phone #1 *

Parent/Guardian #2:*

Emergency Phone #2 *

INSURANCE INFORMATION (Both lines MUST be completed.)

Family Health Insurance Company:*

Policy Number:*

Allergies, Reactions, Medical or Dietary Limitations

Please enter any allergies or other medical conditions, dietary restrictions and other items that we should be aware of:

Will your student be bringing prescription or over the counter medicine to the retreat?*

YesNo

Name and strength of medicine(s)*

Please be as specific as possible for each medicine

Prescribing Doctor*

Enter NA for any over the counter medicine

Dosage and Directions*

Please indicate the medicine and be as specific as possible

Purpose of the medicine(s)*

Any additional notes

Parents/Guardians:

I hereby request that an authorized representative of Bishop Chatard High School make available the above described prescription to my son/daughter/youth listed above during the retreat, in accordance with the information I have entered above.

Parent Responsibility for use of Inhaler

I confirm that my child/youth has been made aware by me that his/her inhaler is for his/her use only and may not be shared with others.

My child/youth has been made aware by me that he/she must notify a staff member immediately following each use of an inhaler in case follow-up response is needed.

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Bishop Chatard High School is not responsible for ensuring that the above medication(s) is taken and is relieved of responsibility for the benefits or consequences of the child/youth using or not using the medication as described above.

By typing in my name below, I indicate that I have read this information and consent to the information.

Parent/Guardian Signature for medicines*

First NameLast Name

Participation Consent & Relinquishing of Claims against BCHS

Read the BCHS Parent/Guardian Permission Policy

Parent/Guardian Signature*

By typing your name here, you. the parent/guardian, are indicating you've read the permission policy & officially grant permission for your student's participation

Current Date

Parent/Guardian Contact Email*

If you have any concerns, please contact Brian Farrell, bfarrell@bishopchatard.org.