Destination: Cardinal Pacelli School  

Camp duration: 9:00am – 12:00 pm daily during your grade specific dates above.

Packed Snack: Yes

Name of Teacher/ Adults in Charge: Maggie Dickey and Tiffany Hayward

Emergency Contact phone number of Adult in Charge: 812-363-3808, 513-305-6292

Details of Camp: Math, grammar/phonics, reading fluency/comprehension, and writing through hands-on learning activities. 

*Payment is nonrefundable

*If you consent to medical treatment, click Yes and complete this section. Otherwise, click No and complete the section "Refusal to Emergency Medical Treatment".

If attempts to reach the above contacts have been unsuccessful, I hereby give my consent for the administration of any treatment deemed necessary by an emergency medical technician or by the preferred practitioners and hospital in which you list below. If such designated practitioners are not available, I provide consent of medical care by another licensed physician, dentist or other hospital reasonably accessible. 

I agree to authorize the school authorities to treat minor students in the event that I cannot be reached in an emergency. I hereby permit the concerned school authorities to call 911 and/or to contact the medical facility or physician selected by the school to provide proper treatment to the above named student. I will be responsible for all expenses arising in association with such treatment. 

Prescription or Over-the-counter Medication – I certify that I have in my file in the school office, a current profile enlisting necessary medication that the above student must take. 

Acknowledgement of Notification Regarding Risk hereby acknowledge that I have been notified whether or not the activities involved in this summer camp are to be considered ‘high risk’ to participants. 

Indemnity and Waiver of Claim, the undersigned, parent/legal guardian of above named student, hereby agree to indemnify and hold harmless the school, its employees, volunteers, the school district, its governing board, the individual members thereof, and all the other district officers, agents and employees from any liability, lawsuit, cost, expense, or claim of any type whatsoever (including legal fees) for any harm, injury, or death arising out of the above mentioned activity, as a condition of the student participating in the same.

This authorization does not cover major surgery unless the medical opinions of two other licenses physicians or dentists concurring in the necessity for such surgery are obtained before the surgery is performed. 

Please provide facts concerning the child's medical history, including allergies, medications being taken, and any physical impairments to which a physician should be altered. In none, please enter "N/A"

By Submitting this form and entering my name below, I AM PROVIDING consent to emergency medical treatment as stated in the terms above. 

If you DO NOT want the Pacelli Ski Club and its volunteers to provide medical treatment in your absence, please indicate this by placing your name and the date in the field below. 

By submitting this form and entering my name below, I DO NOT GIVE CONSENT for emergency medical treatment of my child.