Junior Boys Retreat Permission Form 2021-22

Retreats will be held at St. Meindard Archabbey, 200 Hill Drive, St. Meinrad, IN 47577.

Retreat Date *

September 26-27, 2021

April 10-11, 2022

Student's First Name *

Last Name *

Homeroom

Address (Street, City, State, Zip Code) *

Medical & Insurance Information

ALLERGIES, REACTIONS, DIETARY RESTRICTIONS, OR OTHER COMMENTS:

0/300 characters

INSURANCE INFORMATION: (Both lines MUST be completed.)

Family Health Insurance Company: *

Policy Number: *

PHYSICIAN INFORMATION

Physician Name *

Physician Phone *

Physician City *

Emergency Contacts

Emergency Contact Name *

Emergency Phone *

Emergency and Correspondence Email Address *

Parent/Guardian Permissions

RELINQUISH OF CLAIMS AGAINST BISHOP CHATARD HIGH SCHOOL ONLY

I recognize and acknowledge that there are risks in my child’s/ward’s presence and participation in the school sponsored program identified above. I agree to indemnify Bishop Chatard High School and hold it harmless, and I hereby waive and relinquish all claims, including any claims arising out of negligence that I may have against Bishop Chatard High School, its officers, agents, employees, representatives or volunteers arising out of any activity my child/ward participates in while attending the program or in connection with transportation to or from the program.

I agree that my child shall abide by all Bishop Chatard rules and policies. I have reviewed and discussed the rules and policies with my child prior to signing this form. I agree that if my child fails to abide by the rules/policies, or engages in a serious infraction, he or she may be immediately dismissed from the school sponsored program above with no refund and sent home at my expense.

I understand that my child may be photographed, unidentified in group situations; and I hereby grant permission for my child to be photographed & identified for releases to Bishop Chatard and the Bishop Chatard website and/or other promotions.

MEDICAL RELEASE

Our permission is hereby given to the school representative of Bishop Chatard High School to authorize, by his/her signature, whatever medical or surgical treatment may be considered necessary or advisable by the physician or nurse in attendance in the event of an accident or medical emergency involving:

Consent: *

I, as parent/guardian of the above student, understand and agree with the above statement.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I, AS PARENT/GUARDIAN, AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Use your mouse --or-- click and drag -- or -- use your finger on a touch screen to write your name below.

Date *

Parent/Guardian Name (Typed) *

Relationship to Student *

Parent/Guardian Written Signature *

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