JS E R R A C A T H O L I C
H IGH S C H O O L
Freshman retreat
January 23-24, 2015
Important Dates
$100 deposit due Tues, Dec 16
$50 Final Payment due Tues, Jan 13
**deposit and completed paperwork due to reserve your spot!
**payments can be made to JSerra online
Freshman overnight Retreat
Expected time of Departure: Friday, 3:00 PM by the Chapel
Expected time of Arrival: Saturday, 2:30 PM near the Chapel
Mode of Transportation: Charter Bus
Cost: $150 – Please see payment policies below
Retreat location: The Irvine Ranch – Outdoor Education Center
2 Irvine Park Road, Orange, CA 92869
Emergency Number at Irvine Ranch: 714-923-3191
What to bring:
· A sleeping bag and pillow, an extra blanket
· Toiletries
· A washcloth and towel
· Clothes that can get messy
· A sweatshirt or jacket for the evening sessions
· Shoes appropriate for outdoor activities
· A large snack item to share with your fellow students
School Work:
Students will not miss classes J
Departure and Arrival:
We will be leaving for the retreat Friday immediately after school. Please have your student drop off their bags in the Campus Ministry room Friday morning. Then, they can return after school to load their things on the bus. We will be returning from the retreat Saturday around 2:30pm. . The retreat will conclude with Mass in the Chapel at 2:30 pm and parents are welcome and encouraged to attend.
Please leave cell phones at home! They will be confiscated and not returned until the end of the retreat
In order to prevent theft or loss, please do not bring any valuables that cannot be carried with you at all times. JSerra will not be held responsible for any lost or stolen items that occur on this trip.
Dress Code:
Retreat participants are expected to dress in a fashion that represents modesty and good taste. Clothing must cover all undergarments and midriffs. Bikini tops, low cut tops, mini skirts, short shorts, and sagging or other inappropriate attire are not to be worn at any time during the retreat. Please leave behind clothing with vulgar or offensive language or obscene pictures on T-shirts behind. These types of clothing will not be tolerated.
Where will we stay?
Housing will be in several dorm style rooms. No food or drink (except water) will be allowed in the rooms. If there is a medical condition that makes this policy a hardship, we will do our best to accommodate it. Sleeping bags are required; bed sheets or other blankets are completely optional.
What will the weather be like?
Orange, CA can be cold due to the location, please be prepared for possible rain. The nights will be chilly so please pack accordingly.
For your health!
Please be advised to drink lots of water and eat properly. Students are not allowed to carry any over the counter medications or prescription medications either. All medication has to be given to one of the Adult Chaperones with full detailed instructions prior to departure.
What happens if I get in trouble?
If your son or daughter is caught in an act of misconduct, you the parent or guardian will need to drive up and pick them up personally. We are not responsible for any arrests or citations that might come from such activities. All students are asked to follow the rules and JSerra behavioral policies.
Special Diets:
Please advise the retreat director of any dietary needs.
Payment Policies:
The total cost for the Freshman Overnight Retreat is $150 and includes food, lodging, transportation and activities. To sign up for the retreat, please submit a non-refundable deposit of $100 to Campus Ministry by the date listed below for your specific retreat. Final Payment of $50 is due on or before the date listed below. Students may be added following the deadline, based on availability and with payment in full.
Refund Policy: Once submitted, deposits may not be transferred to another date. Refunds, less the non-refundable deposit, will be given if requested 14 days prior to the retreat. No refunds will be given after that time. By submitting your deposit, you agree to these policies.
$100 deposit due Tues, Dec 16
$50 Final Payment due Tues, Jan 13
JSerra Catholic High School
26351 Junipero Serra Road | San Juan Capistrano, CA 92675
Tel: (949) 493-9307 | Fax: (949) 493-9308 | www.jserra.org
Siempre Adelante
FIELD TRIP PARENT AUTHORIZATION AND RELEASE FORM
Form must be completed and returned to the supervising teacher by ______in order to participate in this event.
Student Name: ______Date of Birth: ______
Address: ______City: ______Zip: ______
Field trip to: Irvine Ranch Outdoor Education Center, Orange, CA Purpose: Freshman Overnight Retreat
Date of Trip: January 23-24, 2015 Departure time: 3:00pm Return time: 2:30 pm
Means of transportation: Charter Bus Responsible/Supervising JSerra teacher/staff member: Mr. Eckert and Miss Bass
I hereby request that JSerra Catholic High School (“JSerra”) permit my son/daughter 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.
Parent/Guardian Name: ______Parent/Guardian Signature: ______
Parent/Guardian daytime telephone: ______Cell phone: (______)______
Additional emergency contact: ______Phone Number: (______)______
STUDENT MEDICAL HISTORY/MEDICATION AUTHORIZATION
Allergies/medical problems/disabilities: ______
I have authorized my son/daughter to self-administer the following medications: (check all that apply)
Tylenol _____ Advil _____ Tums _____ Sudafed_____ Clartin______Benedryl_____ triple antibiotic cream _____eye wash _____
I have authorized my student to be administered the following prescription medication(s) (must be in original labeled container and maintained and administered by the field trip supervisor): ______
Written authorization must be on file with Nurses Office for your student to take any medication.
Insurance Company: ______Policy Number: ______
Doctor’s Name: ______Phone Number: (______)______
STUDENT BEHAVIOR CONTRACT
In order to ensure that this program is a positive experience for all involved, I understand and agree to the following while I am participating in this travel experience:
1. During this trip, I realize that I am a representative of the school. At all times, I will observe all school rules.
2. I will cooperate and abide by the rules/guidelines of chaperones, host families, groups and/or designated agencies.
3. I will satisfactorily complete all study, writing or work assignments associated with this program.
4. I understand that possession and/or use of alcoholic beverages, illegal drugs, or tobacco is forbidden.
5. I will dress appropriately for all activities.
6. I will be expected to make restitution for any incurred damage to property or persons, at school or in the home, accidental or otherwise.
I understand that if any of the above is jeopardized by my behavior, my parents will be notified and I will be at risk of being sent home immediately and unaccompanied at my parents/my own expense.
______
Print Student Name
______
Student Signature Date
Dear Parent:
The Field Trip Form must be filled out to indicate the following:
- - Any medical Issue,
- - Check the medications you want administered to your student while on the retreat
- - List any prescription medications they will need to take on the retreat (this is a school sponsored event). Examples of these medications are …
o ADD meds These include Adderall, Ritalin, etc
o Antibiotics These include Amoxicillin, Penicillin, Z-Pak, etc
o Anti-anxiety/depression/seizure medications These include Lexapro, Zoloft, Topomax, Inderol, etc.
o Inhaler meds These include Proventil, ProAir, Xopenex, Albuterol, etc.
o EPIPEN This is for severe allergies that can include Bee stings, peanut/food allergies, etc.
For those students needing to take any prescription medications with them on the retreat including the ones listed above they must attach the following paperwork and bring in the medication with their Field Trip Form to the JSerra Nurse’s Office on week prior to leaving on the trip. Failing to do so will result in them not being able to attend.
Paperwork to be attached:
Parent/Physician Request for Medication Form
The parent will fill out the top of the form, have the student’s doctor fill out the bottom half of the form and fax it to the JSerra Nurse at (949)493-9308. The medication is to be brought to the Nurse’s Office IN ITS ORIGINAL CONTAINER ONE WEEK PRIOR TO THE RETREAT.
All medications are kept with the retreat director or whomever they appoint and will be handed out at the retreat according to the physician’s order.
We wish your student a very spiritual experience on retreat. If you have any questions or concerns please call the Nurse at (949)493-9028 or send an email to .
Thank you for your prompt attention regarding this.
Maureen McCarthy, RN
JSerra Catholic High School
PARENT/GUARDIAN AND AUTHORIZED HEALTH CARE PROVIDER REQUEST FOR MEDICATION
Name of Student: Date:
Birthdate:
Grade:
PARENT/GUARDIAN REQUEST FOR THE ADMINISTRATION OF MEDICATION PRESCRIPTION AND NONPRESCRIPTION
California Education Code Section, 49423 allows the school nurse or other designated non-medical school personnel to assist students who are required to take medication during the school day. This service is provided to enable the student to remain in school and to maintain, or improve his/her potential for education and learning.
I request that medication be administered to my child , in accordance with our physician’s written instructions. I understand that designated school personnel will administer the medication. I will notify the school immediately and submit a new form if there are changes in medication, dosage, time of administration, and/or the prescribing physician and give permission to contact the physician when necessary.
PARENT/GUARDIAN SIGNATURE: Date: Telephone: (Home) (Work) (Cell)
Emergency medicine such as Epi-pen or inhalers may be carried by the student when authorized by a physician and the parent. A second Epi-pen or inhaler should be kept at school for emergency use.
PHYSICIAN REQUEST FOR ADMINISTRATION OF MEDICATION
Diagnosis/reason for Medication:
Medication: Dose: Route: Time:
If PRN: Amount of time between doses Maximum number of doses per day.
Possible reactions: (possible serious reactions with this medication i.e., allergic reactions, localized/general, etc.)
Instructions for emergency care:
The above medication cannot be scheduled for other than school hours. This mediation may be administered by school personel.
PHYSICIAN’S PRINTED NAME:
PHYSICIAN’S SIGNATURE:
Date of request:
Date to discontinue medication:
Office Stamp
EMERGENCY MEDICATION SUCH AS INHALER/EPI-PEN MAY BE CARRIED BY STUDENT:
Physician’s initials
SCHOOL USE
NURSING OFFICE STAFF:
Date:
MEDICATION AMOUNT RECEIVED:
Date: