CSI: Cincinnati 2023 - Oct. 16-21

  • This is to be filled out by parents/guardians only.
  • Info needed:  digital version of health insurance cards; and physician information; 2 emergency contacts, credit card if paying online

Student Information

Gender *
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Class of *

Medical Information

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Will student be bringing medicines (over-the-counter or prescription) with them? *
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Bishop Chatard Medicine Permission
(For Prescription and Over-the-Counter Medications)
 

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.

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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.

Health Insurance Info


Does the student have health/accident insurance? *

INSURANCE INFORMATION: (Both lines MUST be completed.)
A copy of the front and back of the Insurance Card is requested by Tau House. Please scan or even take a photo with your cell phone and upload the photos here.  You can add 2 at one time or upload 2 separate times.  If you experience difficulties, try a smaller file size.

Parent/Guardian Emergency and Contact Information

Waivers, Release of Liability Forms: PLEASE READ THOROUGHLY

Please read all of the following Permission Forms.
Your one signature below will be signing and giving permission to Bishop Chatard HS and to all these organizations and their specifics.
 
Bishop Chatard Permission Policy
Tau House Permission, Emergency & COVID Policy
Matthew 25 Ministries
 
 
CONSENT: * 🛈
Use your mouse or use your finger on a touch screen to enter your electronic signature. Try to write as large as the box allows.
Parent/Guardian Written Signature *
clear

Payment

Cost is $350. You'll have the option on the next page to pay online or mail/bring in a check later. 
Payment *
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