Senior Wilderness Retreat Parent Consent

Required

Senior's NamerequiredHereafter referred to as "CHILD"
First Name
Middle (optional)
Last Name
Hereafter referred to as "CHILD"
Retreat date and location required

Parent/Guardian information

Namerequired
Prefix (optional)
First Name
Last Name
Suffix (optional)
10 digit format, numbers only: no symbols or spaces
Insurance information
 
Parent Consent /  Waiver and Release
Instructions:  Read each paragraph of document and indicate agreement. 

1) I give my permission for CHILD to attend and participate in the Senior Wilderness Retreat in the Red River Gorge area of the Daniel Boone National Forest.  For purposes of this WAIVER AND RELEASE, if the student is over the age of 18, he is still referred to in this form as “CHILD” and all provisions of this form, including but not limited to all waiver and release provisions, shall be fully applicable to him. 

2) I understand and permit CHILD to travel via school bus to and from this retreat.  I understand that accommodations on this retreat will be primitive in nature and will include tent camping in a wilderness area.

3)  I understand that accommodations will include no electricity, running water, or climate control.  I understand that CHILD will be fully exposed to the elements and all the hazards therein. I understand that this retreat includes strenuous physical activity which includes hiking over long distances on rough, varied, and rocky terrain.  With this understanding, I HEREBY WAIVE AND RELEASE, indemnify, hold harmless and forever discharge Saint Xavier High School (“St. X”) and its agents, managers, employees, officers, directors, affiliates, successors and assigns, of and from any and all claims, demands, debts, contracts, expenses, causes of action, lawsuits, damages and liabilities, of every kind and nature, whether known or unknown, in law or equity, that I or CHILD ever had or may have, arising from or in any way related to CHILD’S participation in the Senior Wilderness Retreat.

4)  I understand that the activities that said CHILD will participate in may be inherently dangerous and may cause serious or grievous injuries, including bodily injury, damage to personal property and/or death. These conditions are characterized by cold temperatures, potential hazardous weather conditions, hazardous, rough and exposed hiking, proximity to dangerous cliffs, entrapment, falls, falling trees, limbs and rocks, diseases, wild animals, and proximity to open flames.

5) I understand that, because of the remote location of the retreat, medical treatment could be delayed for long periods of time.  On behalf of myself, CHILD, my heirs, assigns and next of kin, I and said CHILD waive all claims for damages, injuries and death sustained to me, my CHILD or my property, that I or said CHILD may have against the aforementioned released party to such activity.  

6)  I attest CHILD has the necessary and requisite skills to participate in all facets of, and activities of and requested of this retreat, except as noted below. The nature of the activities has been fully disclosed and any flyer, advertisement, or brochure relating to the participating activities is expressly made a part of this WAIVER AND RELEASE. I further agree and warrant that if at any time I believe conditions to be unsafe, I will immediately exercise my parental/guardianship rights and discontinue further participation by said CHILD in the activity. 

7) By this waiver, I, on behalf of said CHILD, acknowledge that participation in retreats conducted by St. X is completely voluntary. 

8) By this waiver, I, on behalf of said CHILD, further acknowledge that at any of the above-described retreat events or gatherings, I or my CHILD may suffer illness, including exposure to COVID-19, personal injury, disability, pain and suffering, death, damages and/or losses. I, INDIVIDUALLY AND ON BEHALF OF MY CHILD, HEREBY FREELY, VOLUNTARILY AND EXPRESSLY WAIVE, RELEASE, DISCHARGE, INDEMNIFY AND AGREE NOT TO SUE ST. X, ITS EMPLOYEES, REPRESENTATIVES OR AGENTS, AND HOLD THEM HARMLESS FROM ANY NEGLIGENCE ON THE PART OF ST. X, ITS EMPLOYEES, REPRESENTATIVES AND AGENTS CAUSING ANY ILLNESS, PERSONAL INJURY, DISABILITY, PAIN AND SUFFERING, DEATH, DAMAGES, LOSSES, CLAIMS, ACTIONS, DAMAGES, COSTS OR EXPENSES WHICH MAY ARISE, DIRECTLY OR INDIRECTLY, FROM THE CHILD’S PARTICIPATION IN ANY ST. X RETREAT PROGRAM, OR ANY OTHER GATHERING SPONSORED BY OR UNDER THE SUPERVISION OF ST. X.  

9) By this Waiver, I, on behalf of said CHILD, assume any risk, and take full responsibility and waive any claims of personal injury, death or damage to personal property associated with St. X, including but not limited to participating in wilderness retreat activities, or using the facilities and its equipment or engaging in other related activities on and off the premises. 

10) This WAIVER AND RELEASE contains the entire agreement between the parties, and supersedes any prior written or oral agreements between them concerning the subject matter of this WAIVER AND RELEASE.  The provisions of this WAIVER AND RELEASE may be waived, altered, amended or repealed, in whole or in part, only upon the prior written consent of all parties. The provisions of this WAIVER AND RELEASE will continue in full force and effect even after the termination of the activities conducted by, on the premises of, or for the benefit of, St. X whether by agreement, by operation of law, or otherwise.  

Electronic Signaturerequired

I AFFIRM THAT ENTERING MY HOME/PRIMARY PHONE NUMBER AND VALID 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
Namerequired
First Name
Last Name
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