Appalachian Immersion Trip Permission Form 2022

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Appalachian Immersion Trip Permission Slip

Bishop O'Connell is offering a Service-Learning field trip with our partners at the Appalachian Institute as part of Religion Course 9458:  Disciples of Christ in Society:  Catholic Social Teaching and Appalachia. 

Sunday - Thursday,   April 24-28, 2022, Wheeling and Charleston, West Virginia

Bishop O'Connell will provide transportation to and from school. Detailed information is available on Canvas in the Module on "Appalachian Trip" and provided at the information sessions.  Inquiries can be directed by email to Dr. Coolidge at jcoolidge@bishopoconnell.org.   

Cost:  $325 per student.  Financial Aid is available.  Please submit payment through this form or by check payable to:  Bishop O'Connell High School, Department of Religion.  
 

Namerequired
First Name
Last Name
Must contain a date in M/D/YYYY format

As the parent/legal guardian of (student names above), permission is hereby given for my child to participate in the Service activity chosen above. The field trip will run from approximately 9:00 am on April 24 to 5:00 p.m. on April 28th.  I understand and acknowledge that participation in the activities involves inherent risks of injury to my child including risks associated with transportation by motor vehicle. I agree to indemnify Bishop O’Connell H.S., Volunteers, and the Diocese of Arlington for any costs or expenses arising out of my child’s participation in the activities including the cost of any medical care given my child or any expenses or fees incurred in any lawsuit arising as a result of any damage or injuries caused by my child in the course of his or her participation in the activity. I further give my consent that in my absence the above-named minor is admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures, and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named minor. I understand that in the event my child becomes ill with a communicable illness during the trip, I have to make immediate arrangements to retrieve my child from the trip location.

Parent/Guardian Namerequired
First Name
Last Name
Person to notify if Parent/Guardian is unavailable. required
First Name
Last Name

Student Medical Information

Family Physician required
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First Name
Last Name
Must contain a date in M/D/YYYY format
Parent Signature
$325.00

Payment Information

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