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Sophomore Retreat Permission Slip/Medical Information Form

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Retreat Registration is not complete until both this form and the SignUp Genius are submitted. The SignUp Genius link will appear on the confirmation screen once the "Submit" button is clicked for this form. It is also on the "Retreats and Service" page.

I give permission for my daughter, to attend her off-campus retreat.

Daughters First Name*

Answer Required

Last Name*

Answer Required

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

By typing your name you are providing a digital signature*

Answer Required

Date Signed*

Answer Required

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

By typing your name you are providing a digital signature*

Answer Required

Date Signed*

Answer Required

Please Fill In Parental Information Below

First Name*

Answer Required

Last Name*

Answer Required

Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

Email*

Answer Required

Mobile Phone*

Number Required

Home Phone*

Number Required

Work Phone*

Number Required

Please Fill In Insurance Information Below

Parent Carrying Child*

Answer Required

Employer*

Answer Required

Medical Insurance Carrier*

Answer Required

ID Number*

Answer Required

Group Number*

Answer Required

By typing your name you are providing a digital signature*

Answer Required

Date Signed*

Answer Required

IF APPLICABLE: PARENT REQUEST FOR SCHOOL PERSONNEL TO DISPENSE MEDICATION

Any known food allergies or health conditions of daughter*

Answer Required

Name of Prescription Medication(s) including Dosage/Frequency

Answer Required

Prescribing Doctor

Answer Required

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

Answer Required

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

By typing your name you are providing a digital signature for the administration of medicines listed*

Answer Required

Date Signed*

Answer Required

Confirmation Email

Email Required