Concordia Academy > CA Families > Documents & Links > Senior Retreat Form Senior Retreat Form Step 1 of 5 20% Student and Guardian Contact InformationThis is an overnight event. Please have images of the back and front of student’s medical insurance card ready to upload for page 2 of this form. Please have student and parent present when completing page 3 of this form.Student Name(Required) First Last Student Date of Birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AgeStudent Home Address(Required) Street Address City ZIP / Postal Code Student Phone (Mobile)(Required)Parent/Guardian Name(Required) First Last Relationship Parent/Guardian Phone (mobile)(Required)Parent/Guardian Email(Required) Enter Email Confirm Email Emergency Contact Name (must be different than parent/guardian listed above)(Required) First Last Relationship Emergency Contact Phone (Mobile)(Required)Emergency Contact Email(Required) Enter Email Confirm Email Insurance InformationPrimary Health Care Provider(Required)Insurance Policy #(Required)Name of Policy Holder(Required)Upload image of medical insurance card (front).(Required)Max. file size: 50 MB.Upload image of medical insurance card (back).(Required)Max. file size: 50 MB.Medical InformationAny known allergies (including drug allergies or severe allergies to animals, foods or other substances)?(Required) Yes No If yes, please describe.Date of last tetanus shotMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Does your student currently take any medication?(Required) Yes No Medication student is presently taking (include dosage and reason for each medication listed):* NOTE: All prescription and OTC medication must be in original container with dosage information and will be turned in to the medical coordinator upon departure.List any physical factors or injuries that might affect student’s activity or would be necessary for a physician to know when caring for your child.Other questions or concerns.Parental Permission – If an emergency arises, it might be necessary to seek care for your child before staff can contact you. Such care can be provided only if you inital and sign the authorization below.Signature of Parent/Guardian – In case of minor illness or injury, I give my permission for the supervisor of my child to administer necessary treatment and/or first aid. In case of emergency, I hereby authorize the official representative of my child’s school or the person in charge of the program to permit a physician/hospital to administer emergency or surgical care, and I further authorize any licensed physician, medical facility or trained emergency technician to administer emergency or surgical care.(Required) Please read and complete this page with your student. Both parent and student signatures are required.Parent/Guardian: I give permission for my son/daughter to participate in this trip and I have read and understand all the information and rules provided. I understand that Concordia Academy will provide adult chaperones who will carry out adequate and appropriate supervision during the trip and whose primary responsibility it is to keep the students safe while traveling. I also understand that unanticipated situations can arise which are not reasonably in the control of the supervising adults. Sign below to agree.(Required)Parent/Guardian: I have completed the medical release form and have listed all medications my child is currently prescribed. I understand that students may not carry prescription medications. I will provide medications needed for the trip in the original container with the dosage listed to the medical coordinator who will make sure my child receives the medication as prescribed. In the case of inhalers and emergency medication (such as EpiPen, Glucagon, Diastat), my student will carry those with them at all times. (It is recommended that the adult medical chaperone is provided with and carries a duplicate set in case of emergency.) Sign below to agree.(Required)OTC Medication(Required) I understand that students are not to carry complete packages of over-the-counter (OTC) medication in their luggage or bags. I give permission for my child to request OTC medication as needed from the medical coordinator. This includes pain reliever, cough medicine, cold and allergy relief, and digestive aids. No, please do not give my child the OTC med/s listed in the next section. Please do not administer the following OTC meds to my student:Parent/Guardian Signature – OTC Medication rules(Required)Student: I have read, understand, and agree to abide by the rules and behavior expectations for this trip. I will be accountable to my classmates and adult chaperones and will follow the itinerary given. I understand that Concordia Academy’s policies as outlined in the Student Handbook extend into this trip as a school sponsored event. Sign below to agree.(Required)Student: I understand that the use and/or possession of controlled substances and weapons will result in immediate dismissal from the trip on the first available trip home, unchaperoned, and at student’s expense. Subsequent discipline will follow school policy as well as Minnesota State High School League consequences. Sign below to agree.(Required) Participant Consent I have fully read and agree to the following: This Waiver and Release of Liability (this “Release”) is executed by the undersigned in favor of Camp Omega, Inc., a Minnesota nonprofit corporation, and its directors, officers, employees, volunteers, agents and affiliates (collectively, “Camp Omega”). I desire to participate in certain activities directly or indirectly offered by Camp Omega, which activities may include, but may not be limited to, camping, boating, canoeing, kayaking, sailing, swimming, horseback riding, fishing, hiking, cookouts, climbing, high & low ropes course, sports, games, skiing, snowshoeing, snowmobiling, sledding, broomball, snow tubing, archery, hatch throwing, wagon/pontoon rides, and other activities. I also understand that I will be asked to perform incidental work or tasks for Camp Omega, including, but not limited to, lodge/facility cleaning, cabin cleaning or general camp pick-up. Camp Omega will not allow me to participate in any of the above named activities (the “Activities”) without this Release, and therefore I freely and voluntarily execute this Release to participate in the Activities. • Waiver and Release. I understand that the Activities present risks of potential injury, illness, death, expense, loss or damage which risks may be inherent in the Activity, arise from the negligence of Camp Omega or arise from the negligence of others, such as other participants in the Activities. I hereby assume all risks associated with the Activities and I hereby waive, release, discharge and hold Camp Omega harmless from any and all injury, illness, death, expense, loss or damage of any kind or nature whatsoever, either in law or in equity, and whether accrued now or in the future, that may arise from or be related to the Activities, my presence at any Camp Omega’s facility or Activity, or in travel related to Camp Omega or the Activities, even if the same is caused in whole or in part by any negligence of Camp Omega. I understand that I am not required to participate in any particular Activity, and that I am responsible for ceasing any Activity if I experience any pain or discomfort related thereto, or if I become uncomfortable with any potential risks of such Activity. • Consent to Medical Treatment. I authorize Camp Omega to provide or authorize any medical treatment or other care that it deems appropriate in any circumstance where, in Camp Omega’s judgment, I do not have, or do not readily appear to have, the ability to make reasonable medical treatment and care decisions for myself. I hereby waive, release, discharge and hold Camp Omega harmless from any injury, illness, death, expense, loss or damage whatsoever that may arise from or may be related to such medical treatment or other care, even if the same is caused in whole or in part by any negligence of Camp Omega. I understand that Camp Omega does not provide medical insurance and that I am responsible for the cost of any medical treatment or other care that I receive. • Conduct. I understand that I must fully and faithfully abide by all rules and requirements of Camp Omega, and obey the directives of any Camp Omega staff. Any failure to do so may result in such disciplinary or remedial action as Camp Omega deems appropriate, which may include, but not be limited to, suspension of privileges, suspension of my participation in Activities or immediate expulsion from Camp Omega’s facilities, all without refund. • Appearance Release. I grant Camp Omega the right to take and use photographic images, video recordings and audio recordings of me, and Camp Omega may use my name, face, likeness, voice and appearance in advertising, promotion or educational materials. I disclaim any right to such images and recordings, and to any royalties or other benefits derived therefrom. This Release is intended to be as broad and inclusive as permitted by law. If any clause or provision of this Release is held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not affect the remaining provisions of this Release which shall continue to be fully enforceable.Participant Full NameParticipant SignatureParent/Guardian Authorization – If the participant above is a minor, (i.e., under the age of 18 years old), the undersigned, being the parent or guardian of the above minor with custody, have read this Release, agree to its terms and authorize the above minor to participate in the Activities on the terms set forth herein.(Required) This Waiver and Release of Liability (this “Release”) is executed by the undersigned in favor of Camp Omega, Inc., a Minnesota nonprofit corporation, and its directors, officers, employees, volunteers, agents and affiliates (collectively, “Camp Omega”). I desire to participate in certain activities directly or indirectly offered by Camp Omega, which activities may include, but may not be limited to, camping, boating, canoeing, kayaking, sailing, swimming, horseback riding, fishing, hiking, cookouts, climbing, high & low ropes course, sports, games, skiing, snowshoeing, snowmobiling, sledding, broomball, snow tubing, archery, hatch throwing, wagon/pontoon rides, and other activities. I also understand that I will be asked to perform incidental work or tasks for Camp Omega, including, but not limited to, lodge/facility cleaning, cabin cleaning or general camp pick-up. Camp Omega will not allow me to participate in any of the above named activities (the “Activities”) without this Release, and therefore I freely and voluntarily execute this Release to participate in the Activities. • Waiver and Release. I understand that the Activities present risks of potential injury, illness, death, expense, loss or damage which risks may be inherent in the Activity, arise from the negligence of Camp Omega or arise from the negligence of others, such as other participants in the Activities. I hereby assume all risks associated with the Activities and I hereby waive, release, discharge and hold Camp Omega harmless from any and all injury, illness, death, expense, loss or damage of any kind or nature whatsoever, either in law or in equity, and whether accrued now or in the future, that may arise from or be related to the Activities, my presence at any Camp Omega’s facility or Activity, or in travel related to Camp Omega or the Activities, even if the same is caused in whole or in part by any negligence of Camp Omega. I understand that I am not required to participate in any particular Activity, and that I am responsible for ceasing any Activity if I experience any pain or discomfort related thereto, or if I become uncomfortable with any potential risks of such Activity. • Consent to Medical Treatment. I authorize Camp Omega to provide or authorize any medical treatment or other care that it deems appropriate in any circumstance where, in Camp Omega’s judgment, I do not have, or do not readily appear to have, the ability to make reasonable medical treatment and care decisions for myself. I hereby waive, release, discharge and hold Camp Omega harmless from any injury, illness, death, expense, loss or damage whatsoever that may arise from or may be related to such medical treatment or other care, even if the same is caused in whole or in part by any negligence of Camp Omega. I understand that Camp Omega does not provide medical insurance and that I am responsible for the cost of any medical treatment or other care that I receive. • Conduct. I understand that I must fully and faithfully abide by all rules and requirements of Camp Omega, and obey the directives of any Camp Omega staff. Any failure to do so may result in such disciplinary or remedial action as Camp Omega deems appropriate, which may include, but not be limited to, suspension of privileges, suspension of my participation in Activities or immediate expulsion from Camp Omega’s facilities, all without refund. • Appearance Release. I grant Camp Omega the right to take and use photographic images, video recordings and audio recordings of me, and Camp Omega may use my name, face, likeness, voice and appearance in advertising, promotion or educational materials. I disclaim any right to such images and recordings, and to any royalties or other benefits derived therefrom. This Release is intended to be as broad and inclusive as permitted by law. If any clause or provision of this Release is held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not affect the remaining provisions of this Release which shall continue to be fully enforceable.Parent/Guardian Signature(Required)Dietary Restrictions(Required) My student has dietary restrictions My student does not have dietary restrictions Dietary Restrictions RequestIn order to accommodate the dietary restrictions of guests, complete the field below, sign and submit at least one week prior to the start of the event. If this document is submitted, the expectation is the participant has needs that they must adhere and will be expected to consume the food specifically prepared for them. If they choose otherwise, fees to cover the costs of purchasing and preparing will be assessed. Explain your special dietary restrictions (food allergies, intolerance, personal choice, etc.):
