ICCP Day of Service 2022 – IC Catholic Prep

Student's Name *

First

Last

Student's Grade Level *

Mother's Name *

First

Last

N/A if not applicable

Father's Name *

First

Last

N/A if not applicable

Emergency Phone Contact *

Primary Email *

Confirm Email

(This will be where all communications from IC Catholic Prep will be sent.)

Student's Birthdate *

Student's Health Insurance Company *

Policy Holder *

Policy Number *

Identification Number *

Authorized Physician *

Physician's Phone Number *

Medical Permission *

By checking this box, I consent to allow my child to participate in the ICCP field trip for Day of Service. I also grant permission for the administration of First Aid to my child by the people in charge of the event, and those transporting my child/teen to and from the program as their judgment deems advisable, and to make the necessary referrals to qualified physicians for treatment of illness or accidents of a more serious nature. I understand that I will be promptly notified in the event of any serious illness or accident and prior to any major surgery, except when delay in such communication would endanger life. In case of medical emergency, I understand that every effort will be made to contact the parent/guardian of the participant. In the event that I cannot be reached, I hereby give permission to the physicians selected by the adult staff to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery, if deemed necessary for my child/teen.

Digital Signature (Full Name) *

Day of Service Fee *

Price: $ 25.00

A $1 handling/processing fee will be added to your order. You will be taken to PayPal to process the payment.

Verification *

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