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    Juliana Strenger
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    6 views4 pages

    JSD Permission

    Uploaded by

    Juliana Strenger

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    Junior Service Day Permission Form Student Name: Wana Strenggr APID + Holly Hill Farm Date 2la/14/a3, Signature Page 1 Student Name + APD Date : Junior Service Day Permission Form Junior Service Day Permission Form, Page 1 Please read and then fill in any missing/required information below the form. Junior Service Day Permission Form 1-1 Section 1 Cardinal Spellman High School Parental/Guardian Permission Form On Thursday, December 15, 2022 our junior class will participate in their annual Service Learning Day. We have partnered with a variety of different agencies, which will have our students going to food banks, farms, nursing homes, and donation centers and learn what it means to Love, Give, and Serve. All students will need to bring their own lunch on this day. Most sites will depart from Spellman and return to Spellman. There are a few sites where juniors will need to provide their own transportation. Parents will be notified if your child signed up for this kind of site. This day will take place within the normal school hours. However, some sites will be finished up closer to 1:00 pm, while other sites will be finished closer to 2:00 pm. Students are not allowed to bring medications with them and arrangements MUST be made with the school nurse BEFORE the trip occurs if medication is needed during the day. If your child needs an Epipen, there will be a trained chaperone onsite. All students are expected to behave in accordance with the guidelines set forth in the Student Handbook. Parents will be called in the event of unacceptable behavior. *(If you are filling out this permission form online please scroll down to the bottom of this page where you can add/update the requested infomation. You may also print out this page and send it in with your child) Signed and (2). (parent's / guardian's signature) (1)Home Phone: Work Phone: Cell Phone: 508~ 5oa- 2573 (2)Home Phone: Work Phone: Cell Phone: 508-56A “2165 In case of emergency by reason of accident or illness, Cardinal Spellman High School will make every effort to reach at least one parent/guardian involved. Should this be impossible, the school wishes to be authorized to proceed as rapidly as possible to seek medical attention, Please sign the statement below, giving requisite authority. Page 2 Student Name APD Date : Junior Service Day Permission Form Junior Service Day Permission Form, Page 4 Please read and then fill in any missing/required information below the form. Medical Insurance Name: Hacuard Pilgrim Medical Insurance ID #_HH6340183 Allergies_Amayicillion “If neither parent can be reached, please communicate with — {Ni whose relationship is. jeans other and whose phone number's ~ 56% AGQou a understand that the inabilly to reach the above named person will not affect the authorization to take emergency procedures herein before given to the school Date: 12/14/22 Parent/Guardian Signatures: "Please also read and sign the back. Retum completed form to tH appropriate Spellman staff member. OVER RELEASE, INDEMNIFICATION AGREEMENT AND MEDICAL POWER OF ATTORNEY 1 the lawful parent or guardian ot Juliana Stren ger (*my chit’) irrevocably release from all ability, and hereby agree to indemnify and hold harmless the Roman Catfole Archbishop of Boston, both individually and in his capacity as trustee for the benefit of the Roman Catholic Archdiocese of Boston and all parishes within the Archdiocese, including but not limited to Cardinal Speliman High School, andthe officers, agents, representatives, volunteers, chaperones, clergy, religious and employees of either the Archdiocese of Boston or any parish or youth ministry thereof ("Agents") from any and all liability, actions, causes of action, claims, judgments, cost or expenses, including but not limited to attorneys’ fees, known or unknown at ths time, arising out of or in any way related to any injury or illness or other damages to person or property incurred by my child while participating in o traveling to or from the noted event. | agree to instruct my child to cooperate with and follow the Instructions of CSHS and Its Agents, including but not limited to those in charge of the activity. In the event my child does not cooperate with or follow the Instructions of CSHS or Its Agents, or violates the ‘Archdiocese of Boston Code of Behavior (which I acknowledge that | have reviewed), | agree that | shall, at my sole cost and expense, arrange for the immediate transportation of my child from the event to my custody, if so requested by CSHS or any ofits Agents. appoint CSHS or Its agents, including but not limited to those who are acting as leaders of the activity as my attorney in fact to act for me in my name and on my behalf in any way that I would, in the reasonable and sole judgment of CSHS or Its agents, be expected to actif | were personally present, with respect to the following matters if any injury, illness or medical emergency occurs during the activity/event To give any and all consents and authorizations to any physician, dentist, hospital or other persons or institutions pertaining to any ‘emergency medications, medical or dental treatments, diagnostic or surgical procedures or any other emergency actions as our attorney, in fact, shall deem necessary or appropriate for the best interest of my child. understand that CSHS and Its Agents will make a reasonable attempt to contact me as soon as possible in the event of medical ‘emergency involving my child. The powers and authority granted herein may be revoked by written notice delivered in-hand to CSHS or Its agents who are then acting or who have previously acted hereunder. Without such written notice, this power of attorey shall not be affected by my disability, incapacity or adjudicated incompetence. This power of attorney shall lapse automatically upon completion of the activity and the return of my child to CSHS. As evidenced by my signature below, CSHS and Its agents, including but not limited to CSHS Chaperonels, may use my child's portrait, photograph or video for promotional purposes related to the advancement and development of the ministry of the Roman Catholic Church and the Archdiocese of Boston, and hereby release RCAB and Its Agents from any liability resulting from such use. Page 3 Student Name + APD Date : Junior Service Day Permission Form Junior Service Day Permission Form, Page 1 Please read and then fill in any missing/required information below the form. If any change occurs in the information provided by the parent or guardian with respect to emergency contacts or medical information, the appropriate Agent will be provided with written notification of such change as soon as possible. understand and agree that CSHS and Its agents, including but not limited to the CSHS Chaperone/s, are not and shall not be responsible for assuring that my child takes any medications, prescription or otherwise, which are indicated for my child have carefully read this statement, and my signature acknowledges that | fully understand and agree to its content and meaning. | give my permission for my child to attend the event. x_Kort Steenoge OY in (Print Name) pate_1al Had (Parent/Guardian signature) 1 [PARENTIGUARDIAN Tact nage 2 | ParentiGuardian Name 3 | ParenvGuardian Home F 4 | Parent(Guardian Cell @ 5ob-Sea-aGs 5 [ ParenGuardian Work F © | Health Insurance Carrier Honora Ciocw 7 [Poly Holders Name E

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