2019 High School Spring Retreat
EVENT NAME: Spring Retreat
COST: $40 payable to IHM
DESTINATION: Geneva Camp and Retreat Center, 3995 Lakeshore Dr N, Holland, MI 49424
DATE/TIME DEPARTURE & RETURN: Saturday April 13 meet at IHM parking lot at 10am/ Sunday April 14, return for 11am Mass at IHM
Email address *
Child(ren)'s Name(s) *
Your answer
Parent/Guardian Name(s) *
Your answer
Phone Number During Event *
Your answer
Medical Information *
Please list doctor's name and phone number any allergies, medications or pertinent comments
Your answer
Health Insurance Data *
Company, policy, group and contract
Your answer
Signature *
Please type your name to certify above Statement of Consent
Your answer
Statement of Consent *
I hereby consent to participation by my child(ren) in the event described above. I understand that the event will take place away from the school/parish grounds. I further consent to the conditions stated above on participation in this event, including the method of transportation. In consideration of my child being allowed to participate in this event, I agree to waive and release, and indemnify and hold harmless Immaculate Heart of Mary School/Parish, any and all affiliated organizations, its/their employees, agents, representatives, volunteers and drivers, from any and all claims I or my child may have, excluding claims for intentional misconduct or gross negligence, arising from or relating to my child’s participation in this event. I authorize Immaculate Heart of Mary School/Parish to obtain necessary medical treatment for my child in case of illness, injury or accident. This release form is completed and signed of my own free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence. I grant to IHM Parish/School my consent without reservation to use, assign, convey, reproduce, copyright, publish or sell my/my child's name, voice and/or image that arises from participation.
A copy of your responses will be emailed to the address you provided.
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