Shadow Day

Student preferred name or nickname

Current School*

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Please list your CURRENT grade in school

Student cell phone number

Please list the participant's cell phone number below if you consent to your daughter receiving occasional text messages from Saint Ursula Academy.

Home Phone Number

Please list ethnicity

Parent(s) Name*

Parent Email Address*

Parent Cell Phone Number*

Please list your dietary restriction/allergy. We will do our best to accommodate dietary needs.

Medications taken regularly:

Medical Conditions/Impairments (e.g. epilepsy, diabetes, asthma):

Additional emergency contact:

Emergency contact phone number

PERMISSION, RELEASE, & AUTHORIZATION TO SEEK MEDICAL TREATMENT

By registering for this Saint Ursula Academy admissions event, you represent, warrant, and agree that: • You are the custodial parent/legal guardian of the minor Child attending the event and you give permission for your Child to participate in the event; • You, on behalf of yourself and your Child, release from all liability, indemnify, and hold harmless Saint Ursula Academy, its trustees, officers, administrators, employees, agents, and volunteers from any and all liability, claims, judgments, damages, costs and expenses, including attorneys’ fees, arising out of any injury, illness, infectious and/or communicable disease (such as MRSA, influenza, or COVID-19), or death, (including any injury, illness, infectious and/or communicable disease, or death caused by the negligence of Saint Ursula Academy or any of its trustees, officers, administrators, employees, agents, or volunteers) incurred by your Child while participating in the event, traveling to or from the event, or while using the facilities or equipment of Saint Ursula Academy; • You will not bring or prosecute or allow to be brought or prosecuted (including, but not limited to, prosecution by subrogation) in your name, or on behalf of your Child, any claims, lawsuits, or actions against Saint Ursula Academy or their trustees, officers, administrators, employees, agents, or volunteers; • Saint Ursula Academy and its agents may use a photograph, video, or other likeness of your Child, electronically or in print, for promotional purposes, website, and office functions unless you notify the Admissions Department electronically at [email protected] before the start of the event; • The agents of Saint Ursula Academy who are acting as leaders of the event may seek medical treatment for your Child in the event of any injury, illness, or medical emergency during the event or related travel. An agent of Saint Ursula Academy will make a reasonable attempt to contact you as soon as possible in the event of a medical emergency involving your Child; • This Permission, Release, and Authorization is intended to be as broad and inclusive as permitted by the law of the State of Ohio, and if any portion is declared invalid, the balance shall, notwithstanding, continue in full legal force and effect. This Permission, Release, and Authorization shall be construed in accordance with the laws of the State of Ohio, excluding, and irrespective of, any choice of law principles; and • You have carefully read and understand and accept the terms and conditions stated herein and you acknowledge and agree that this Permission, Release, and Authorization to Seek Medical Treatment is effective and binding upon you, your Child, and your personal representatives, estates, assigns, heirs, and next of kin.

Signature

By initialling in the box below, I consent to the terms detailed in the "Permission and Release of Legal Guardian on Behalf of Minor" statement listed above.**

Today's Date

Help SUA Create Your Ideal Shadow Experience

Please indicate below if you have a current student (it is recommended this be a freshman or sophomore) with whom you would like your daughter to spend the day. You may list 2 choices and we will do our best to pair her with one of the hostesses you've listed below.

Other interests not listed

What THREE areas from the above list are most important to you?

What area of our campus are you the most excited to see?

SCHEDULE A SHADOW DAY AT SUA

Shadowing program dates through November

PERMISSION, RELEASE, & AUTHORIZATION TO SEEK MEDICAL TREATMENT

Help SUA Create Your Ideal Shadow Experience