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KAIROS 53 RETREAT
PARENTAL/GUARDIAN CONSENT FORM AND LIABILITY WAIVER
Return this form to the Campus Ministry Office by September 27, 2017. Space is limited.
Participant’s Name: ______________________________________Grade:____________________________
Birth Date: _____________________________ Sex: _____________________________________________
Parent/Guardian’s name: ___________________________________________________________________
Home Address: ___________________________________________________________________________
City: ______________________________State:_____________Zip:________________________________
Home Phone: ______________________ Mom’s Cell: __________________ Dad’s Cell: __________________
I, __________________________, grant permission for my child, ___________________________________,
Parent/Guardian’s Name Child’s Name
To participate in this youth ministry 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 Bishop
Manogue Catholic High School. A brief description of the activity follows:
Type of event: Kairos 53 Retreat Individual in charge: Matt Galli
Destination of event: Zephyr Point Presbyterian Conference Center Lake Tahoe, Nevada
Estimated time of departure and return: 2:30pm Sunday, October 22, 2017 to 7:00pm Tuesday, October 24,
2017.
Mode of transportation to and from event: Bus for retreatants and carpool for leaders
Cost: $250 due with permission slip (non-refundable). Make checks payable to BMCHS. Lost Key
Fee $35.00.
As parent and/or legal guardian, I remain legally responsible for any 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 Bishop Manogue Catholic High School, its officers, directors and agents, and the Diocese of Reno,
chaperones, or representatives associated with the event for reasonable attorney’s fees and connections arising in
connection therewith.
Signature: ___________________________________________ Date: _____________________________
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. (Of the following statements pertaining to medical matters, sign
only those that are applicable.)
Emergency Medical Treatment: 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. In the event of an emergency, if you are unable to reach me at the above numbers, contact:
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Name & Relationship: ________________________________________ Phone: ______________________
Family Doctor: _______________________________ Phone: _____________________________________
Family Health Plan: ______________________ Policy #:________________________________________
Signature: ____________________________________________ Date: _____________________________
Other Medical Treatment: In the event it comes to the attention of the school, its officers, directors and agents, and
the Diocese of Reno, chaperones, or representatives associated with the activity that my child becomes ill with
symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called collect (with phone charges
reversed to myself).
Signature: ______________________________________________ Date: ___________________________
Medications: My child is taking medication at present. My child will bring all medications necessary and such
medications will be well-labeled. Names of medications and concise directions for seeing that my child takes such
medication, including dosage and frequency of dosage, are as follows:
_____________________________________________________________________________________________
_______________________________________________________________________________
Signature: ______________________________________________ Date: ___________________________
No medication of any type, whether prescription or non-prescription, may be administered to my child unless the
situation is life threatening and emergency treatment is required.
Signature: ______________________________________________ Date: ___________________________
Or
I hereby grant permission for non-prescription medication (such as aspirin, throat lozenges, cough syrup) to be
given to my child, if deemed appropriate.
Signature: ______________________________________________ Date: ___________________________
Specific Medical Information: The school will take reasonable care to see that the following information will be
held in confidence.
Allergic reaction (medications, food, plants, insects, etc,):________________________________________
Immunizations: Date of last tetanus/diphtheria immunization: _____________________________________
Does your child have a medically prescribed diet or are they vegetarian/vegan? _______________________
Any physical limitations? _________________________________________________________________
Is child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, bedwetting, fainting?
______________________________________________________________________________
Has child recently been exposed to contagious diseases or conditions, such as mumps, measles, chicken pox, etc.? If
so, date and disease or condition: _________________________________________________
You should be aware of these medical conditions of my child:
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For office use only:Payment: Cash Check FA
Name on Check: _____________________________________________________Check Number: ______________