Student Name
*
First Name
Last Name
Birthdate
MM
DD
YYYY
Current Grade
*
Current School
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
How did you hear about us?
Parent Name
*
First Name
Last Name
Parent Phone
*
(###)
###
####
Parent Email Address
*
Parent Name
First Name
Last Name
Parent Phone
(###)
###
####
Parent Email
Shadow Day Emergency Contact
First Name
Last Name
Relationship
Phone Number
(###)
###
####
Emergency Contact 2 Name
First Name
Last Name
Relationship
Phone Number
(###)
###
####
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 Milwaukee.
Medical
*
By checking the box below, I agree to keep Chesterton Academy of Milwaukee 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. A copy of the Allergy/Asthma Action Plan will be kept in the school office as well. This form is available here or through the office.
Further, I authorize Chesterton Academy of Milwaukee's 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.
COVID-19 Waiver
*
COVID-19 *
COVID-19 has been declared a worldwide pandemic and is extremely contagious. Even with implementation of safety protocols,
Chesterton Academy cannot guarantee that you, members of your household, or your child(ren) will not become infected with COVID-19 and cannot guarantee that shadowing at Chesterton Academy and/or participation in Chesterton Academy’s activities will not increase your risk and/or your child(ren)'s risk of contracting COVID-19. By signing this COVID-19 Pandemic Waiver, I/we acknowledge the contagious nature of COVID-19, that my/our child(ren) and I/we may be exposed to or infected by COVID-19 by shadowing at the school and/or by participating in school activities, and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I/we understand that the risk of becoming exposed to or infected by COVID-19 at the above-named School may result from the actions, omissions, or negligence of myself/ourselves and others, including, but not limited to School employees, volunteers, students, and their families. I/we further agree on behalf of myself/ourselves, my/our child (student) named herein, and my/our heirs, successors, and assigns, to absolutely release, defend, indemnify, and hold harmless the named School, associated parishes and school systems, principals, teachers, volunteers, and the Archdiocese of Milwaukee, its directors, officers, employees, attorneys, agents, representatives, and insurers/third-party administrators (hereinafter collectively referred to as the "Indemnified Parties") from any and all claims or causes of actions in any way related to COVID-19, brought by any person or entity, including but not limited to, all claims and causes of action based on the alleged negligence of the Indemnified Parties, other third parties, or my own negligence. By checking below, you signify this is to be used as your signature.
Requested Host Student
If you have a preferred host student, enter name here.
First Name
Last Name
