MATER DEI HIGH SCHOOL Deadline for Application and $140:
PARENT PERMISSION SLIP Friday, November 4
Senior Retreat (Space is limited—1st come, 1st serve)
Tuesday, November 15-Wednesday, November 16
To the Principal of Mater Dei High School:
I hereby permit ________________________________________________________(_______)____________
Student Name Home Phone
to participate in the Senior Class Retreat, at Irvine Outdoor Education Center. I understand that the
students must be dropped off at 8:15 a.m. on Tuesday, November 15, and picked up at the retreat center
by Wednesday, November 16th at 6:00p.m. I have been informed that parents are invited to join their
children for mass at 5:00 to close the retreat. I agree to direct my child to cooperate and conform with the
directions and instructions of the supervisory personnel in charge of the trip. Should it be necessary for
my child to have medical treatment while participating in this trip, I hereby give the school personnel
permission to use their judgment in obtaining medical service for the student and I give permission to the
physician selected by the school to render medical treatment deemed necessary and appropriate by the
physician.
Retreats are very powerful moments in a student’s life. Often, emotions are felt and subsequently expressed.
There are trained leaders on the retreat to assist the students in case a difficult issue may arise on the retreat. In
some situations these will require follow-up, especially in the case of danger to self or others, or the reasonable
suspicion of child abuse. Our retreat directors are mandated by law to take all reasonable steps necessary to
protect the child, including informing the appropriate authority.
I agree that in the event my child is injured as a result of his or her participating in this field trip, including
transportation to and from such activity, through the negligence of the school, or any of its agents or employees,
recourse for the payment of any resulting hospital, dental, medical or related costs and expenses will first be had
against any accident, hospital or medical insurance, or any available benefit plan of mine or of my spouse.
_______________________________________(_______)__________________(______)____________________
Parent/Guardian Signature Home Phone Cell Phone (Mom or Dad)
______________________________________________________________________________________
Address City State Zip
_______________________________
Date
EMERGENCY CONTACT OTHER THAN PARENTS:
_______________________________________________________(______)_________________________
Name Relationship Phone
MEDICAL INFORMATION:
_______________________________________________________(______)_________________________
Physician Phone
Date of Last Tetanus Shot: ______________________________________________________________
Allergies: ____________________________________________________________________________
Drug Allergies:________________________________________________________________________
Does student take any medications? Yes _____ No _____
**If yes, please list medications and possible side effects: _________________________
______________________________________________________________________
Does student have permission to be given Tylenol or Advil? Yes _________ No
**No medications may be administered unless listed on this form which is signed by parent/guardian
Mater Dei High School
1202 West Edinger Avenue
Santa Ana, California 92707-2191
714-754-7711
I understand fully that a class retreat is spiritual in nature, for the purpose of deepening
my understanding of who God is in my relationship to Jesus as well as my family, friends
and neighbors.
A retreat experience includes prayer, group dynamics, discussions, singing, games, time
for reflection, making and sharing gifts and Celebration of the Eucharist. All participants
are encouraged to join in these activities.
Although a retreat provides the opportunity to get away from the normal routines of
school, work, family, etc. it is not a license to act or engage in any behavior unbefitting
our Christian and Catholic morals. All standards of behavior as outlined in the Mater Dei
student handbook shall be observed and followed at all times. Any serious infraction of
these rules will prompt a phone call to your parents or guardian; immediate removal from
the retreat by a parent or guardian and notification to the Dean’s Office at Mater Dei.
This is a school-sponsored event.
I understand that this retreat is something that I am making a commitment to. I know that
I must dedicate myself to the full time commitment required for the retreat.
I agree with the above statements and promise to direct myself in accordance with all
school policies as well as further directions on this retreat. Failure to do so shall result in
the appropriate consequences mentioned above.
Student Signature _____________________________________ Grade _____________
Parent/Guardian Signature __________________________________Date ________