Retreats: Seniors 2024-25

Campus Ministry

2024-25 Senior Retreat Permission

The first October Senior Retreat will take place in Lindenwood Retreat Center. The others will be held at St. Joseph Retreat Center, Tipton.

Student First Name:*

Student Last Name:*

Retreat Date*

October 6-7, 2024October 27-28, 2024February 2-3, 2025March 9-10, 2025

Parent/Guardian#1:*

Relationship to student*

Emergency Phone #1 *

Emergency Contact #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, medical conditions, dietary restrictions and other items that we should be aware of:

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

YesNo

Name and strength of medicine(s)*

Please be as specific as possible for each medicine

Prescribing Doctor*

Enter NA for over the counter medicines

Dosage and Directions*

Please indicate the medicine and be as specific as possible

Purpose of 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.

------------

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

Please read the official School Waiver, Release and Consent Agreement here.

Parent/Guardian Signature*

By typing in your name here, you. the parent/guardian, are officially granting permission for your student's participation and medical release and confirm you have read the BCHS Agreement above

Current Date

Parent/Guardian Contact Email*

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

Reply to -Admin