Student Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Parent Name *

First Name

Last Name

Parent Phone *

(###)

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Phone Number *

(###)

###

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Photography Release *

I consent to any still or electronic image, audio and/or video recording, in which my child or family members may appear during the shadow day, for potential promotional purposes of Chesterton Academy of Annapolis.

Yes

No

Medical *

By checking the box below, I agree to keep Chesterton Academy of Annapolis informed of my emergency contact information and any special medical needs and/or conditions my child may have. If my child has an inhaler, Epi-pen, or other emergency medication potentially needed for any condition, I agree that it is my child's responsibility to keep this medication, and a copy of his or her Allergy/Asthma Action Plan, with him or her at all times during off-site activities or field trips. I agree to provide a copy of the Allergy/Asthma Action Plan and any other Medical Emergency Plan to Chesterton Academy of Annapolis office. This form is available through the office. Further, I authorize Chesterton Academy of Annapolis' staff, instructors, board members, and volunteers to seek and provide emergency medical care in the event of an injury, illness, allergic reaction or other emergency.

Yes

Permission *

By entering my name below, I grant permission for my student listed on this form to spend the school day as shadow for the above date at Chesterton Academy of Annapolis. This may include transportation from Mass to the Chesterton Academy campus. I understand that my child will participate in the daily school activity and I warrant that my child is in good health. In consideration of my child’s participation, I agree to indemnify Chesterton Academy of Annapolis from any claims or lawsuits brought against Chesterton Academy of Annapolis by myself, my child or others, that arise out of any behavior by my child. I also agree to pay reasonable attorney’s fees or expenses incurred by the school in defense of such a claim/suit.

First Name

Last Name