Mater Dei Catholic High School

PERMISSION TO PARTICIPATE IN SENIOR OVERNIGHT RETREAT
"Living for God with Reckless Abandon"

EXCULPATORY RELEASE and INDEMNITY AGREEMENT
&
AUTHORIZATION FOR EMERGENCY MEDICAL
AND DENTAL TREATMENT

Permission

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* 1. The undersigned parent(s) or legal guardian(s) of (Please Put Your Student Name)

First Name

Last Name

a student at MATER DEI CATHOLIC HIGH SCHOOL (hereafter “MDCHS”), hereby grant(s) permission for him/her to participate in off campus activity as follows: Whispering Winds Catholic Camp in Julian, and further consent(s) that he/she may be transported to such activity in a private automobile operated by an adult or student volunteer or by public or chartered bus.

IT IS UNDERSTOOD that adult supervision of the off campus activity will be under the direction of MCHS and its staff, and the mandatory conditions for volunteer student drivers are: a valid California Drivers License; parent permission to operate the automobile to transport other students; the automobile to be driven is in good operating condition; car pool insurance - $250,000/$500,000 bodily injury and $25,000 property damage; and only the correct number of students are to be in the vehicle. This means ONE STUDENT PER SEAT BELT. Transporting students in the back of a pick-up is NOT ALLOWED.

Release and Indemnity
In consideration for the above student being permitted to participate in the off campus activity specified above, the undersigned agree(s) to not make or join in a claim or civil suit for injury, death or property damage against an entity affiliated with the CATHOLIC DIOCESE OF SAN DIEGO, including MDCHS, their administrators, staff or volunteers participating in the above off campus activity and hereby release(s) all entities affiliated with the CATHOLIC DIOCESE OF SAN DIEGO, including MDCHS, and their administrators, staff and volunteers from all actions, claims and demands the undersigned or the student may hereafter have for injury, death or property damage arising out of negligence or strict liability, as consistent with public policy, arising out of participation in the off campus activity specified above.

Further, if a claim or civil suit is made by the student or someone in a representative capacity on behalf of the student for injury, death or property damage, arising out of participation in the off campus activity specified above, the undersigned agree(s) to indemnify and hold harmless all entities affiliated with the CATHOLIC DIOCESE OF SAN DIEGO, including MDCHS, their administration, staffs or volunteers, from any and all such claims, suits, damages, including judgments and /or settlements, whether such claims arise out of the negligence of any such entity or affiliated individual, whether an employee, agent or volunteer, and whether such negligence is active or passive and whether individually or in concert with others.

AUTHORIZATION

The undersigned as parent(s) or legal guardian(s) of the above named minor student hereby authorize and grant to the supervising or participating adult permission in the event of illness or injury while participating in the off campus activity specified above to consent to the following:

Any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care to be rendered to the minor under the general or special supervision and upon the advise of a physician and surgeon licensed under the provisions of the Medical Practice Act or to consent to an X-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care to be rendered to the minor by a dentist licensed under the provisions of the Dental Practice Act.

Said, authorization to include the release of any medical or dental records to the attending physician or dentist for review.

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* 2. Telephone Number of Parent/Guardian:

Home Phone Number:

Work Phone Number:

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* 3. Name of Alternate if the above cannot be contacted:

First Name:

Last Name:

Phone Number:

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* 4. Family Health Insurance Company & Policy #

Family Health Insurance Company Name:

Family Health Insurance Company Policy #

Family Health Insurance Company Phone Number #

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* 5. Name of Student:

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* 6. Date of Birth of Student:

Date / Time

Date

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* 7. Please list any food allergies or special dietary needs:

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* 8. Please list any medications/dosage/frequency:

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* 9. Digital Signature of Parent/Guardian (Please sign this agreement by typing your full name below)*

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* 10. Date

Date / Time

Date

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* 11. Senior Retreat Behavior Contract

As you prepare for the senior retreat, please keep in mind that the theme for this retreat is “Living for God with Reckless Abandon”. We are all called to put God first in our lives and, especially on this retreat, your purpose for going should be to grow closer to God and strengthen your faith life. God has great things in store for you on this retreat, if you are open to receiving them.

You will be expected to act as mature young adults on this retreat, follow all school policies, and contribute fully to enriching your retreat experience. Please fully complete the form below.

Please Type Full Student Name If You Agree To the Above:

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* 12. STUDENTS

Follow all rules and directions of the chaperones, Whispering Winds staff and bus driver.

Stay within the boundaries of the campground. (This is for your safety)

Not to use profane language or inappropriate gestures.

Agree to be back on time from all breaks and free time.

At bedtime, I understand that I will have 30 minutes to prepare for bed; lights will then be turned off and I will be allowed to speak softly for one hour. At that time, I will be expected to be silent and go to sleep.

Agree to have a respectful attitude and participate fully in all activities and events.

Agree not to take any illegal substances, tobacco, e-cigarettes or devices to the retreat.

Agree to turn in my cell phone to retreat leaders during the retreat and leave all other electronic devices at home. (Cameras allowed)

Agree to stay in my cabin from bedtime until 7 a.m. and not go outside the dorms during the night.

Agree to respect the privacy of the dorms – girls only in the girl’s dorm and boys only in the boy’s dorm.

Please Type Full Student Name If You Agree To the Above:

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* 13. PARENTS

I agree to make restitution for any incurred damage to retreat house/bus property or persons, accidental or otherwise.

I agree that if my son/daughter’s behavior warrants him/her leaving the retreat, I will come to Julian to pick them up no matter the time of day or night.

Please type Full Parent Name If You Agree to the Above:

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* 14. Parent Cell Phone (to reach at night if necessary)

Phone Number

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* 1. The undersigned parent(s) or legal guardian(s) of (Please Put Your Student Name)

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* 2. Telephone Number of Parent/Guardian:

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* 3. Name of Alternate if the above cannot be contacted:

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* 4. Family Health Insurance Company & Policy #

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* 5. Name of Student:

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* 6. Date of Birth of Student:

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* 7. Please list any food allergies or special dietary needs:

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* 8. Please list any medications/dosage/frequency:

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* 9. Digital Signature of Parent/Guardian (Please sign this agreement by typing your full name below)*

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* 10. Date

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* 13. PARENTSI agree to make restitution for any incurred damage to retreat house/bus property or persons, accidental or otherwise.I agree that if my son/daughter’s behavior warrants him/her leaving the retreat, I will come to Julian to pick them up no matter the time of day or night.

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* 14. Parent Cell Phone (to reach at night if necessary)

* 13. PARENTS

I agree to make restitution for any incurred damage to retreat house/bus property or persons, accidental or otherwise.

I agree that if my son/daughter’s behavior warrants him/her leaving the retreat, I will come to Julian to pick them up no matter the time of day or night.