Student Name:  

Medical Conditions or Special Notes:

I am the parent or guardian of above said student. (Only Parent or Guardian may submit this form).

Parent/Guardian Name:  

Parent/Guardian Home Phone Number:  

Parent/Guardian Cell Phone / Pager Number:  

Online Registration Indicates Acceptance of the Following Consent and
Emergency Medical Release Statement:
I hereby give permission for my child listed above to attend to attend the Seventh Grade Overnight Trip on August 23rd through the 24th and to be transported by school bus, private bus, public transportation, van or private vehicle(s) as determined by the school. For myself and the named child; I hereby waive and release any claim against Holy Spirit Preparatory School and its board, employees, servants and agents for any injury or loss incurred by my child during the field trip (save for any personal injury directly resulting from gross negligence on the part of the school) and agree to indemnify the school against any expenses, loss or damages incurred as a consequence of any action or inappropriate inaction on the part of my child. I confirm that there are no medical or other circumstances that should be known to the chaperone(s) that are not noted in the Medical Conditions or Special Notes box above.

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