* Required

Student Leaders are selected and given a code by Campus Ministry. Questions? Contact Mr. Zach Eckert at zeckert@jserra.org.​​​​​​​



I hereby request that JSerra Catholic High School ("JSerra") permit my student(s) identified above to participate in the foregoing activity. I am aware that there are certain risks associated with such participation. I hereby knowingly and voluntarily assume any and all such risks. Moreover, for valuable consideration, the receipt and sufficiency of which are hereby acknowledged, I, individually and on behalf of my minor child, hereby knowingly and voluntarily release, acquit, and discharge JSerra, and each of its officers, directors, employees, agents, volunteers, and representatives, of and from any and all liability, claims, demands, and/or causes of action, relating to or arising from such participation.

I hereby authorize JSerra personnel, as agent for the undersigned, to consent to any x-ray, examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and render under the general or special supervision of any physician and/or surgeon licensed under the provisions of the Medical Provisions Act on the medical staff of any accredited hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power on the part of our aforesaid agent to give specific consent to any and all such diagnosis, treatment or hospital care, which the aforementioned physician, in exercise of his best judgment, may deem advisable.


This section pertains to your student(s)'s medical issues and the following while away on the retreat (if applicable):

  • Any medical issues
  • Any medications you want administered to your student(s) while on the retreat
  • List any prescription medications your student(s) will need to take on the retreat (this is a school-sponsored event). Examples of these medications are ADD medications such as Adderall, Ritalin, etc.; antibiotics such as Amoxicillin, Penicillin, Z-Pak, etc.; anti-anxiety/depression/seizure medications such as Lexapro, Zoloft, Topomax, Inderol, etc.; inhaler meds such as Proventil, ProAir, Xopenex, Albuterol, etc.; and EpiPen for severe allergies that can include Bee stings, peanut/food allergies, etc.

If your student(s) require(s) the administration of prescription medications, you must submit the Request for Medication Administration Form to the Nurse's Office.

Please Note: students are not allowed to carry over-the counter or prescription medications unless it is an Epipen and/or Inhaler accompanied with a Request for Medication Administration Form. All other medications will be dispensed by a designated JSerra staff member.

Please list allergies/medical problems/disabilities. If none, please put "N/A."​
I have authorized the designated JSerra staff member to administer to my student the following medication(s):​
I have authorized my student to be administered the following prescription medication(s), which must be in original labeled container and maintained and administered by the field trip supervisor. If none, please put "N/A."​
If your student has dietary needs such as gluten-free, peanut allergy, vegetarian, etc., please list them below. If none, please put "N/A."​​