All Grades Retreat Permission and Medical Form

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Student First Name*

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Student Last Name*

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By signing my name below, I indicate that I understand and agree with the following:

I give permission for my daughter to attend her off-campus retreat.
In consideration of the making of arrangements for this activity by Sacred Heart Academy, I hereby release and save harmless the school of Sacred Heart Academy, Louisville, Kentucky, and any and all personnel of Sacred Heart Academy from any and all liability for any injuries, loss, or other claims arising out of or resulting from this trip and activity.
We understand and support the fact that the student must comply with the directions given by the Academy to the group involved in the activity
Cancellation Fee: I understand that I will be charged a non-refundable cancellation fee if I/my daughter cancels her retreat less than 14 calendar days before the first day of retreat. The amount of the fee will be determined by the type and length of the retreat and will be communicated to students and parents when retreat assignments are announced at the end of August. Cancellation fees will be collected via FACTS.
Senior Retreat only: I understand that the applicable retreat fees will be collected via FACTS in the weeks leading up to retreat.

By typing your name you are providing a digital signature*

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Date Signed*

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Emergency Medical Treatment Approval*

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By checking this box I hereby give permission for my daughter to receive emergency medical treatment in the event of illness while on the trip with Sacred Heart Academy (SHA) authorized personnel.

Limits of Confidentiality: Retreat is a special experience and confidentiality is of the utmost importance. However, there are limits to confidentiality when a student’s safety comes into question. *

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By checking this box I indicate that I am aware that all Sacred Heart Academy faculty and volunteers are required by law to report when a student reveals issues of abuse of any kind (even if the abuse occurred in the past) or indicates situations of harm to self or others (in the past, present or future).

Please Fill In Parental Information Below

First Name*

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Last Name*

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Street Address*

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City*

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Zip/Postal*

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Email*

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Mobile Phone*

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Home Phone*

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Work Phone*

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Please Fill In Insurance Information Below

Parent Carrying Child*

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Employer*

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Medical Insurance Carrier*

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ID Number*

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Group Number*

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IF APPLICABLE: PARENT REQUEST FOR SCHOOL PERSONNEL TO DISPENSE MEDICATION

Any known food allergies or health conditions of daughter*

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Name of Prescription Medication(s) including Dosage/Frequency

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Prescribing Doctor

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Name of Non-Prescription or OTC Medication(s) including Dosage/Frequency

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If applicable, I also request that Sacred Heart Academy authorized personnel administer the above medication to my daughter as indicated above. My daughter and I understand that it is her responsibility to ask for the medication at the appropriate time. I understand that school personnel are under NO obligation to remember to administer the medication. I understand that the medication must be in the original container with the dosage correctly labeled. I understand that SHA personnel will not administer any medication in which the dosage is not indicated on the container.

I agree to release and save harmless any and all SHA personnel and authorized chaperones from any and all harm or damages that may happen to my daughter as a result of this request for administering medication or performing basic first aid for my daughter while she is on this trip

Administration of Medicines Approval*

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By checking this box you are providing a digital signature for the administration of medicines listed.

Please fix the highlighted areas below before submitting.

All Grades Retreat Permission and Medical Form