Salesian College Preparatory 2018 Summer School Application


Student's Information

Contact Information

Parent / Guardian Information

Contact Information

Other Emergency Contact Person Information


Course Sign-Ups (check one per session)

Payment Options

The first course will be a $400 and the second course will be an additional $250. Please note that financial aid is not available for Summer School.

If you would like to pay by check, please drop the payment off at the school or mail to:

Salesian College Preparatory
Attn: Eileen Howard
2851 Salesian Ave.
Richmond, CA 94804


2018 Medical Release Form for Summer School


Student Information


Parent/Guardian Information


Student Medical Information

Insurance Information


Medical Release Disclaimer

I hereby give my consent for my child to participate in Salesian College Preparatory Summer School. In rare instances, a medi-cal or surgical emergency requiring treatment arises in which written consent by parents or guardians is legally required, but the proper person cannot be located. In this event, and in order to avoid delay that might jeopardize the life or health of my daugh-ter/son, I hereby provide the following permission, with the understanding that reasonable effort will be made to contact me in an emergency: I hereby grant permission to medical personnel rendering care to my daughter/son to accept from the staff of Salesian College Preparatory which includes its faculty, permission and consent for emergency medical and dental evaluation and treatment, including, but not limited to diagnostic, drug, and/or alcohol testing and/or surgical procedures on my daughter/son. I further give Salesian College Preparatory staff permission to release pertinent health information concerning my daugh-ter/son to the treating hospital and/or physician, and to give the treating hospital and/or physician permission to release copies of all medical records, laboratory and radiology reports to Salesian College Preparatory staff. I agree that I will be responsible for any medical/pharmaceutical costs incurred that are not covered by medical insurance. I also agree that Salesian College Preparatory, including its staff, agents or employees, will not be liable for unknown or unforeseen conditions arising from medi-cal/nursing treatment or medications received by my daughter/son. I voluntarily agree, covenant and promise to accept and as-sume all responsibilities, and risk for injury, death, illness or disease or damage to myself, my daughter/son identified above, or to my property arising from my daughter/son’s participation in Summer School, and the use of the premises, facilities, equip-ment and services offered by Salesian College Preparatory in connection with Summer School. I, for myself and for my daugh-ter/son, voluntarily release and forever discharge and covenant not to sue Salesian College Preparatory and its staff including its coaches, agents or employees, and all other persons or entities affiliated therewith, from any and all liability, claims, de-mands, actions or rights or action, which are related to, arise out of, or are in any way connected with my daughter/son’s partici-pation in Summer School, any and all activities related to Summer School, and the use of the premises, facilities, equipment and services offered by Salesian College Preparatory in connection with Summer School, including, but specifically not limited to any and all negligence or fault of Salesian College Preparatory and its staff, including its faculty. I further agree, promise and covenant, on behalf of myself and my daughter/son specific above, to hold harmless and to indemnify Salesian College Pre-paratory and its staff, including its faculty, agents or employees, and all other persons or entities related to Salesian College Preparatory, from all defense costs, including attorney's fees, or from any other costs incurred in connection with claims for bodily injury, wrongful death or property damage brought by me, my daughter/son, or on our behalf. I further acknowledge that I am in the best position to determine the physical ability of my daughter/son to participate in Summer School, and acknowledge that my daughter/son is in good physical and mental health, and is not suffering from any condition, disease or disablement which would or could potentially adversely affect participation in Summer School. I HAVE READ THIS FORM, FULLY UNDER-STAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND HAVE SIGNED IT FREELY AND WITHOUT INDUCEMENT OR ASSURANCE OF ANY NATURE AND INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS FORM IS HELD TO BE INVALID THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.

I have read and agree to the Medical Release Disclaimer


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