Junior Immersion Consent Form

Junior Immersion 2025

Registration & Consent Form
Location: Monument Crisis Center - 1990 Market Street Concord, CA 94520

Time: 7:45 AM - 2:30 PM

Students will need to bring:
- Water
- Snack
- Lunch
- A non-perishable food item to be donated to Monument Crisis Center such as: cereal, peanut butter, squeezable jelly in a plastic bottle, spaghetti or snack bars
All students will meet at Carondelet High School at 7:45 AM on the day of their field trip and depart by bus at 8:15 AM. Students will return to Carondelet High School by bus at 1:30 PM, where they will conclude their immersion experience with a reflection in the chapel. The estimated end time is 2:30 PM.

In this form you will provide required medical and contact information for Carondelet High School.
Immersion Date*
Student First Name*
Student Last Name*
Student Date of Birth*

MonthDayYear
Date
Student Carondelet Email*
Parent/Guardian 1*

First NameLast Name
Phone Number*

Area CodePhone Number
Phone Number - Alternate

Area CodePhone Number
Email*
Address*

Street Address

Street Address Line 2

City

Zip Code
Parent/Guardian 2

First NameLast Name
Phone Number

Area CodePhone Number
Phone Number - Alternate

Area CodePhone Number
Email
Transportation

The method of transportation that will be used for this field trip: School bus.

Parents/Guardian: Please inital below to indicate that your child may ride on the School bus.
Parent/Guardian Initial*

Clear
General Medical Information

Indicate your student's health considerations and some basic medical information.
Special health considerations (e.g., allergies, dietary needs, limited physical activity, etc.)
EpiPen (Fill in "Yes" or leave blank)
Medications and dosage
Medical Insurance Plan and Number*
Family Doctor*
Doctor's phone number*

Area CodePhone Number
Parent/Guardian Signature

I give permission for my child to go on the above-mentioned field trip. In consideration for securing the arrangements, I hereby release and save harmless the school and its agents from any and all liability for any injury that may occur during this trip.

Our permission is hereby given to the school representative of Carondelet High School to authorize, by his/her signature, whatever medical or surgical treatment may be considered necessary or advisable by the physician or nurse in attendance in the event of an accident or medical emergency involving the above named student.
Parent/Guardian Signing*

First NameLast Name
Signature*

Clear
Should be Empty:

Junior Immersion 2025