* Required

Student Name*required

Student Cell*required

Parent Name*required

Parent Email*required

Parent Cell*required

Select Days to Attend

Tuesday 8/12*

Yes No

Wednesday 8/13*

Yes No

Both 8/12 & 8/13

Yes No

Please RSVP by 7/28.

Attire - shorts & t-shirt.

See you at Rookie Camp!

Visitor Release

The Mount is delighted to have your daughter as our guest. The following information is for emergency purposes and will be shared with our school nurse and Admissions Office on the day your daughter visits.

Student Date of Birth*required

Emergency Contact Name*required

Emergency Contact Phone (preferred #)*required

Emergency Contact Phone (other #)*required

Physician Name*required

List Allergies*required

Does child administer and carry Benadryl or EPI Pen for reactions?*

Yes No

List Medications Taken Regularly*required

List Restrictions to Child's Activities*required

Does child have medical conditions the school should be aware of?*

Yes No

List Medical Conditions *required

Check the following medications your child can receive:*

None Tylenol (Acetaminophen) Advil (Ibuprofen) Aleve (Naproxen) Tums (Antacid) Neosporin (Antibiotic Ointment)

In Case of Emergency

I give qualified personnel permission to treat my child. I give further permission for health related information about my child to be shared with Mount St. Dominic Academy staff on an as needed basis.

Electronic Signature for Release*required

Type your name

Date*required (mm/dd/yyyy)

Date signed

Please send a confirmation email to the address below:

Please provide an email address where we can send a link to your current form.

Email Address :