Freshmen Teambuilding Retreat - Parent Consent

Required

Retreat Attendee's Namerequiredpreferred, common name
First Name
Last Name
preferred, common name
09 _ _ _
Retreat date and location required
Transportation: School bus contracted by Saint Xavier High School.required

Parent/Guardian information

Namerequired
First Name
Middle (optional)
Last Name
Suffix (optional)
10 digit format, numbers only: no symbols or spaces
Insurance information
 
Parent Consent

RELINQUISHMENT OF CLAIMS AGAINST SAINT XAVIER HIGH SCHOOL

To the fullest extent allowed by law, I/We recognize and acknowledge that there are risks associated with my child’s/ ward’s presence and participation in the school sponsored activity.  I agree to indemnify, hold harmless, waive and relinquish any and all claims for personal injuries or property damage I or my son/ward may have against Saint Xavier High School and its officers, agents, employees, representatives or volunteers arising out of, or in connection with the activity in which my child/ward participates, including claims for negligence against Saint Xavier High School.

 

PERMISSION FOR EMERGENCY TRANSPORTATION AND MEDICAL TREATMENT

In case of any medical emergency, I authorize Saint Xavier High School agents, employees, representatives or volunteers to determine, arrange for, or provide appropriate transportation to a medical facility.  I understand that every effort will be made to contact the parent or guardian of the child in need of medical care.  In the event that I cannot be reached, I hereby give permission to the physician or other health care provider to secure any and all treatment deemed necessary for the well being of my child/ward.

Electronic Signaturerequired

I AFFIRM THAT ENTERING MY HOME/PRIMARY PHONE NUMBER AND EMAIL ADDRESS AND BY SUBMITTING THIS FORM CONSTITUTES AN ELECTRONIC SIGNATURE OF THIS FORM. 

10 digit format. Numbers only: no symbols or spaces. (Must contain only numbers)

Permission to provide over the counter pain reliever.

Acetaminophen consent: I authorize Saint Xavier High School employees or agents to provide acetaminophen pain reliever per dosage instructions printed on bottle, if requested by my child/ward. required
Ibuprofen consent: I authorize Saint Xavier High School employees or agents may provide ibuprofen pain reliever per dosage instructions printed on label, if requested by my child/ward. required