Junior Retreats 2026-27

Junior Fellowship Retreat Permission 2026-27

Retreats will take place at Fatima Retreat House in Indianapolis.

Student Name

First NameLast Name

Retreat Date

Click here for more information about the retreat.

Parent/Guardian #1

Relationship to student

Parent/Guardian Contact Email

Emergency Phone #1

Format: (000) 000-0000.

Emergency Contact #2

Emergency Phone #2

Format: (000) 000-0000.

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:

Prescription/Over the Counter Medication Permission

If your minor becomes unwell during the retreat, do you give permission for BCHS staff to administer over the counter (OTC) medications according to the labeling instructions?

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

Name and strength of medicine(s)

Please be as specific as possible for each medicine

Prescribing Doctor

Enter NA for any over the counter medicines

Dosage and Directions

Please indicate the medicine and be as specific as possible

Purpose of the medicine(s)

Any additional notes

Parents/Guardians:

I give permission for an authorized representative of Bishop Chatard High School to make the prescription medication listed above available to my student during the retreat, in accordance with the information provided above.

Parent Responsibility for Use of Inhaler

I confirm that I have instructed my student that their inhaler is for their use only and may not be shared with others.

I have also instructed my student to notify a staff member immediately after each use of their inhaler in case follow-up care is needed.

Bishop Chatard High School is not responsible for ensuring that the medication is taken and is not responsible for the benefits or consequences of my student using or not using the medication as described above.

By typing my name below, I confirm that I have read and understand the information above and consent to these provisions.

Parent/Guardian Signature for Medications

First NameLast Name

Participation Consent & Relinquishing of Claims against BCHS

Read the BCHS Parent/Guardian Permission Policy

By typing your name below, you, the parent/guardian, grant permission for your student to participate, authorize the medical release, and confirm that you have read and agree to the BCHS Agreement above.

Parent Guardian Signature

First NameLast Name

Current Date

Questions? Please contact Brian Farrell at bfarrell@bishopchatard.org.

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