SCHS Parent/Guardian Permission Slip
for Junior Retreat 2010 |
| When you submit this form you will be taken to a secure on-line site to make your payment of $30.70 ($30 retreat cost, $.70 on-line processing fee.) If you wish to pay by check, please do NOT use this form. There is a link to a printable version of the permission slip at the bottom of this page. |
Students Full Name:
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Please enter your student's name. |
Assigned Retreat Date (please choose one):
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Please make a selection. |
Parent/Guardian's Name:
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Please enter your name. |
Email:
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Please enter your email address.Invalid format. |
Home Phone:
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Please enter your home phone number.Invalid format. |
Secondary Phone (Please check what type of phone):
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By typing your name below and checking the "I Consent" box, you agree that:
I hereby consent to participation by my child in this school-sponsored event that requires transportation to a location away from the school site. This activity will take place under the guidance and direction of school employees and/or volunteers from Skutt Catholic High School. Please note that there will be times when your child will be permitted to enjoy the camp area, go on walks, etc. in small groups within a reasonable radius of the main center without direct adult supervision.
A brief description of the activity follows:
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- Activity: Junior Retreats
- Destination of Event: Camp Cedars, Cedar Bluffs, NE
- Cost: $30.70
- Date and Departure time: Wednesday, April 14th or Wednesday, April 21st - 7:50 am
- Anticipated return time to Skutt Catholic: 5:15 pm, retreat concludes about 6:30 pm
- Method of transportation: Buses
- Supervised by: Designated faculty
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As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor ("participant").
I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend Skutt Catholic High School, its officers, directors, and agents, and the Archdiocese of Omaha, chaperones, or representatives associated with the event, from any illness, injury, or cost of medical treatment, arising from or in connection with my child attending the event described above, that is not the result of intentional neglect or willful or wanton misconduct by the school, its agents, representatives or employees.
Medical Matters: I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor.
I consent to the above stipulations.
Please check this box to consent to the stipulations.
Parent/Guardian Name:
Please enter your name. This constitutes your legal digital signature.
Date:
Please enter today's date.The date should be entered as mm/dd/yy. |
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(In the event a parent/guardian cannot be reached) |
| Name of Contact and Relationship to Student: |
Contact Phone: |
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Please enter the name and relationship of your emergency contact. |
Please enter your contact's phone number.Invalid format. |
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| Family Doctor: |
Doctor Phone: |
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Please enter the name of your family doctor. |
Please enter your doctor's phone number.Invalid format. |
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| Number of parents planning to attend the dinner at 5:15 pm: |
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Please enter the number attending dinner.Please enter a number. |
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YES! I want to help make the Junior Retreat successful! Please check below if you are interested in any of the following ways. Thanks for volunteering! You will be contacted with the details if your help is needed.
I would like to provide a dessert or a snack
Set-up
Clean-up
Both
If any of the above are checked, please let us know the best way to reach you:
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| Please submit by Friday, March 19th. |
Please note any questions, special medical concerns, or current medications here: |
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