Sophomore Retreat - TIGERS IN THE CITY

Retreat Attendee's Namerequired

First Name

Last Name

Student IDrequired

Retreat daterequired

October 1

January 14

February 4

February 25

St. X will be providing transportation for this event via school bus, to and from the retreat locations. Students will be accompanied by adult supervision.

· Harbor House @ 2231 Lower Hunters Trace 40216

· Franciscan Kitchen @ 748 S.Preston St, Louisville, KY 40203

· Home of the Innocents @ 1100 E. Market St., 40206

· The Arthur S. Kling Senior Center @ 219 W Ormsby Ave, Louisville, KY 40203

Transportation: School bus contracted by Saint Xavier High School.required

I agree

Parent/Guardian information

Address 1required

Namerequired

First Name

Middle (optional)

Last Name

Suffix (optional)

Address 2

Cityrequired

Staterequired

Zip Coderequired

Parent's Emailrequired

Emergency Contact Namerequired

Emergency Contact Phonerequired

10 digit format, numbers only: no symbols or spaces

Insurance information

Insurance carrier / provider

Member Name

Member ID

Group ID

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 agree

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

Parent's home / primary Phone Numberrequired

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

Email Address

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

I agree

I do not agree

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

I agree

I do not agree

List any medical conditions that you would like the retreat director to be aware of while your son is on retreat. Include any allergy information. All prescription medications must be in its original packaging.

Sophomore Retreat - TIGERS IN THE CITY - Parental Consent

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