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GVSD OFF-SITE ACTIVITY(IES) CONSENT OF PARENT/GUARDIAN AND ACKNOWLEDGEMENT OF RISK

To be completed for: a) Day Field Trips as determined by Administration


b) All Detailed Field Trips (Overnight or Longer)
Please read both si!s of this onsent and Ac!no"ledgement of #is! form$ larify any %&estions or concerns "ith the teacher'
leader ()FO#) signing it$
PROGRAM/ACTIVITY INFORMATION " S#!$i%i$s to b! &tt&$h! (i!' T!&( s$h!)*!)
AT*+*T,(-): .odiac -ports Program
DAT)(-): -eptember /01234&ne /015
*637A#8) P7O6): (/02) 9/53:00:
SC+OOL RESPONSI,ILITIES
The school "ill ma!e every reasonable effort to ens&re or ascertain that:
a$ The staff; vol&nteers and'or service providers involved are s&itably trained and %&alified$
b$ The st&dents are ade%&ately s&pervised over all aspects of the program'activity$
c$ The location(s) &sed are appropriate and safe for the activity(ies) and gro&p$
d$ )%&ipment &sed has been inspected and deemed appropriate and safe$
e$ A -afety Plan is in place to identify and manage !no"n potential ris!s$
f$ An )mergency Plan is in place to deal "ith an in<&ry or illness to one of the st&dents$
POTENTIAL KNOWN RISKS
Potential ris! of associated sport in<&ries and'or transportation ris!s
CONSENT AND ACKNOWLEDGEMENT OF RISK
1$ =ode of Transportation: -chool A&thori>ed +ehicles (y: Division A&thori>ed Drivers
/$ * ac!no"ledge my right to obtain as m&ch information as * re%&ire abo&t this program or activity and associated ris!s and
ha>ards; incl&ding information beyond that provided to me by the school or board$
9$ * freely and vol&ntarily ass&me the ris!s'ha>ards inherent in the program'activity and &nderstand and ac!no"ledge that my
child may s&ffer personal and potentially serio&s in<&ry d&e to an &nforeseen event related to his'her participation$
2$ =y child has been informed that he'she is to abide by the r&les and reg&lations; incl&ding directions and instr&ctions from the
school?s and'or service providers administrators; instr&ctors; and s&pervisors over all phases of the program'activity$
5$ *n the event my child fails to abide by these r&les and reg&lations; disciplinary action may re%&ire his'her e@cl&sion from f&rther
participation; or that * be contacted to have him'her transported home at my e@pense$
A$ * ac!no"ledge that it is my d&ty to advise the school of any medical'health concerns of my child that may affect his'her
participation$
B$ * ac!no"ledge that the school may choose to cancel the trip for <&stified reasons (e$g$; "eather; health advisory; gro&p
behavior)$ * accept that the school "ill not be liable for any costs associated "ith s&ch a cancellation$
:$ * consent that the school and'or activity s&pervisors may sec&re s&ch medical advice and services as they deem necessary for
my child?s health and safety; and that * shall be financially responsible for s&ch advice and services$
C$ (ased on my &nderstanding; ac!no"ledgement; and consents as described herein; * agree that
(6ame of -t&dent) DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDhas my permission to participate in the .odiac -port
Program$

Date: DDDDDDDDDDD 6ame (Please print): DDDDDDDDDDDDDDDDDDDDDDDDDDDDDD -ignat&re: DDDDDDDDDDDDDDDDDDDDDDDDDDDDD
The personal information contained on this form is collected &nder the a&thority of the P&blic -chools Act; the )d&cation Administration Act and the Freedom of *nformation
and Protection of Privacy Act for the p&rpose of participating on school trips$ *f yo& have any %&estions abo&t this form; please contact yo&r school principal$
GVSD OFF-SITE ACTIVITY(IES) CONSENT OF PARENT/GUARDIAN AND ACKNOWLEDGEMENT OF RISK
To be completed for: a) Day Field Trips as determined by Administration
b) All Detailed Field Trips (Overnight or Longer)
FIELD TRIP EMERGENCY MEDICAL INFORMATION (Erite belo" or attach a separate page if more space is needed)
-t&dent 6ame: DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD (irth Date: DDDDDDDDDDDDDDDDDDDDDDDD
=anitoba 7ealth #egistration 6o$ (A3digits): DDDDDDDDDDDDDDDDDD =anitoba P7*6 (C3digits): DDDDDDDDDDDDDDDDDDDDDDDDDDDD
-t&dent -chool Accident *ns&rance: ,es 6o
Allergies (e$g$; specific dr&gs; certain foods; insect stings; hay fever) -pecify:
DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD
#eaction(s) to aboveF DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD
arries )pi penF ,es 6o arries Ana GitF ,es 6o
=edical'physical conditions that may affect participation in the stated program'activity (e$g$; recent illness or in<&ry; chronic
conditions; phobias; etc$)$ (e specific:
DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD
DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD
=edication(s) ta!en (name; reason; dosage; storage; potential side effects'treatment of s&ch):
DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD
DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD
Other 7ealth'=edical'Dietary oncerns:
DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD
DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD
)mergency ontacts:
1) DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD Phone: (7) DDDDDDDDDDDDDDDDDDDD (E) DDDDDDDDDDDDDDDDDDD ()
/) DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD Phone: (7) DDDDDDDDDDDDDDDDDDDD (E) DDDDDDDDDDDDDDDDDDD ()
The personal information contained on this form is collected &nder the a&thority of the P&blic -chools Act; the )d&cation Administration Act and the Freedom of *nformation
and Protection of Privacy Act for the p&rpose of participating on school trips$ *f yo& have any %&estions abo&t this form; please contact yo&r school principal$