Revive and Rekindle at Sandy Cove 
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Email *
Student Name
Student Cell Phone # (if any)
Parent Name
Parent Cell Phone #
Emergency Contact Name
Emergency Contact Phone #
What is the name of the retreat? (Ex: Kairos)
In consideration of the wholesome recreational and learning experience in which my son/daughter ____________________________________________________ will participate, I as parent or guardian of my son/ daughter do hereby agree to allow my son/daughter to accompany the campus minister/teacher/adult chaperone to  this trip.  Departing at 8:00 a.m. on Sept 11 and returning at noon on Sept 13  (union Leaders will depart on the 10th) .  My child has permission to be around docks of the bay and in the swimming pool.  If your child is a non-swimmer please email Mrs. Vawter.  

In consideration of the opportunity for my son and daughter to participate in the Program, I agree to RELEASE AND HOLD HARMLESS AND INDEMNIFY St. Vincent Pallotti High School, their agents, employees and servants from any liability, claims, demands and causes of action arising out of my son/daughter’s participation in the program.      


I hereby grant permission to any staff person to obtain medical care from a licensed physician, hospital, or medical clinic for my son/daughter in the event that I cannot be reached.   


Please write your full name to confirm your acknowledgement that you have read and signed off.

Check if applies to you


I am covered by hospitalization and medical insurance under policy # ______________________issued by_______________________.   

   Please fill out the blanks if this applies to you


I hereby grant permission to any staff person to provide the following over-the-counter drugs to my son/daughter (Select all that apply)  

Add any other medical information concerning medication, allergies, illness, etc.:   


Add any dietary restrictions:      


A copy of your responses will be emailed to the address you provided.
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