Bishop O'Connell HS - Bishop O'Connell High School

Bishop Denis J. O'Connell High School
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Print Student Name
To:
From:
Subject:
Parents/Legal Guardians
Dr. Joseph Vorbach
Senior Retreat
Fr. Phillip Cozzi, our school chaplain, is planning an overnight retreat trip for the
senior class to the Northern Virginia 4-H Educational Center located in Front
Royal, Virginia. Your senior is being asked to sign up in the chaplain’s office for
one of the following dates:
November 13 – 14, 2012 (girls) or December 4 – 5, 2012 (girls)
November 14 – 15, 2012 (boys) or December 5 – 6, 2012 (boys)
The retreats will be chaperoned by DJO faculty and directed by Fr. Cozzi. Bus
transportation will be provided. Each group will depart DJO at 3:00 pm and return
to DJO by 3:00 pm the following day.
COSTS
Student Cost for Buses: $ 50.00
Lodging for one night: Covered by the Chaplain’s Office
Food – three meals: Covered by the Chaplain’s Office
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PARENT PERMISSION
My student has permission to attend the senior retreat at the 4-H Center. I
understand that this permission form and a $50.00 check made out to Bishop
O’Connell High School must be returned to my students’ Religion teacher by
Thursday, October 18, 2012.
__________________
Date
______________________________
Signature of Parent or Guardian
(Please complete emergency information on the back of this form so that the moderator
will have this information should an emergency arise.)
STUDENT RESPONSIBILITY
I accept responsibility for my behavior and acknowledge that school
handbook regulations are in effect during this field trip.
___________________
Date
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Signature of Student

BISHOP O’CONNELL HIGH SCHOOL
History and Consent Form for Field Trip
(Day, Overnight – Academic, Athletic, Club, Activity)
Student’s Name: ___________________________
Student’s Cell #: ___________________________
Event & Location of Trip: Senior Retreat, the Northern Virginia 4-H Center, Ft. Royal, VA
I, _____________________________, hereby give my permission
(Parent/Guardian)
to Bishop O'Connell HS representative, to act in my behalf in case of an accident or illness.
(Teacher/Chaperone)
I authorize a physician, emergency facility, or other qualified medical personnel to administer
necessary emergency treatment. I further understand that every effort will be made to contact
me.
Home Phone: ________________________
Father’s Cell: ________________________
Mother’s Cell: ___________________
Emergency Phone: ________________
Physician’s Name: ____________________________________________________
Physician’s Phone: ____________________________________________________
Is there any physical condition, past or present that we should be aware of
Yes ____________ No _____________ If yes, please explain: ___________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Is student taking a medication regularly Yes ___________ No ___________
Name of medication and condition: ________________________________________________
_____________________________________________________________________________
Any drug allergies ________________________________.
If so, identify drug(s): ___________________________________________________________
______________________________________________________________________________
Any other allergy or condition that we should be aware of: ______________________________
______________________________________________________________________________
PLEASE COMPLETE REVERSE SIDE
______________________________
Signature of Parent/Guardian