Saturday Enrichment Program - March 11th, 18th, & 25th

Student Name(required)

Parent's Cell Phone Number

Parent's E-Mail Address(required)

Student's E-Mail Address

School where student is currently enrolled

Session I Choice(required)

Session II Choice(required)

Is your daughter in good health? Yes

Do you assume all responsibility for the health of your child? Yes

Of the statements pertaining to medical matters, check next to those in accordance with you wishes: In the event of an emergency I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment

I wish to be advised prior to any further treatment by the hospital or doctor

Emergency contact name(required)

Emergency contact relationship(required)

Emergency contact phone number

If your child takes a medication, please list the name, dosage, and administration instructions below:

My daughter has had an episode with the following or has been diagnosed with: Seizures

Asthma

Diabetes

Allergic reactions to the following (foods, latex, etc.):

Has had a medical surgery within the last six months? Yes

Under doctor's care? Yes

Has a medically prescribed diet? Yes

Cardiac condition? Yes

Physical limitations

Immunizations are current and up to date? Yes

You should also be aware of these special medical conditions of my child:

Insurance policy number

I do not carry medical insurance at this time

By typing your full name in this space, you medically consent to the information previously listed on this form. (required)

PERMISSION SLIP FOR PARTICIPATION Parent and student acknowledge and are aware that even with proper supervision, use of protective equipment and strict observance of rules, there are risks inherent in participation in the Saturday Enrichment Program. Parent and student hereby release, hold harmless, indemnify and discharge Mother Seton Regional High School, its employees, agents and volunteers from all liability for damages, loss or injury to persons or property arising out of or in connection with student’s participation in the above described activity that may be filed by, on behalf of, or for the above named student. For purposes of this agreement, liability means all claims, demands, losses, causes of action, suits or judgments of any and every kind that arises from student’s participation in the Saturday Enrichment Program. Parent and student further expressly agree that the foregoing release and waiver provisions are intended to be as broad and inclusive as is permitted by the law and that if any portion of it is held void, voidable, or unenforceable, the remaining portions shall remain in full force and effect. The undersigned has read and voluntarily signs this release and waiver of liability and further agree that no oral representations, statements or inducements, apart from this agreement, have been made.(required) I AGREE and acknowledge my permission for my daughter to participate in the Saturday Enrichment Program

I DO NOT agree and acknowledge my permission for my daughter to participate in the Saturday Enrichment Program

Saturday Enrichment Program – March 11th, 18th, & 25th

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