Emergency Medical Form / Waiver

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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

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