Emergency Medical Form / Waiver printable pdf download

EMERGENCY MEDICAL FORM / WAIVER

Student Name____________________________________________________________

Are there any health conditions the retreat directors should be made aware such as asthma, diabetes, heart

disease, epilepsy or allergies?

__________________________________________________________________________

List any medications being routinely taken.

__________________________________________________________________________

Please list any food restrictions for this student, including if she is a vegetarian.

__________________________________________________________________________

In case of illness or injury, parents will be contacted at home or work. In the event parents/guardians

cannot be reached, permission to authorize emergency treatment is needed.

In the event reasonable attempts to contact me or another authorized person: (names and phone numbers)

__________________________________________________________________________

have been unsuccessful, by signing below I hereby give my consent for the administration of any emergency

medical treatment deemed necessary and/or the transfer of the student to the nearest hospital. This

authorization does not cover major surgery unless the medical opinions of two other licensed physicians or

dentists, concurring in the necessity for such surgery, are obtained before the surgery is performed.

WAIVER

My daughter __________________________ has my permission to attend the Senior Kairos Retreat

at the Maria Stein Retreat Center in Maria Stein, OH. As parent/ guardian, I release Notre Dame Academy,

Toledo Catholic Youth & School Services, and any associated person or agency from any claims in

consideration for the opportunity to participate in this program. I also understand that I will be telephoned

and will pick up my daughter at the academy if she violates the school policy, “NDA has zero tolerance for

possession, use, distribution of alcohol, nicotine, or any prohibited drug” (“possession” includes “being in

the presence of”).

SIGNATURE OF STUDENT ______________________________________________________

SIGNATURE OF PARENT/GUARDIAN ______________________________________________

Home Phone: ___________

Cell Phones – Father: _____________ Mother: ______________

Email Address’s - Father: _____________________ Mother: ___________________________

This form must be turned into Mrs. Smith by Tuesday, October 18

Emergency Medical Form / Waiver