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3/23/2017 Off-Site Activities Enhanced - Home

ConsentofParentorGuardianandAcknowledgement
ofRiskforAandBOffSiteActivity/ies
CorporateRiskManagement

PLEASE READ CAREFULLY


STUDENT NAME: SCHOOL: CopperfieldSchool
Select either (A) or (B)bymarkingan"X"intheboxbelow
(A) Mychild,orI,anIndependentStudentundertheSchoolAct(ineithercase,theStudent),willbegiventheopportunitytoparticipate
intheprogramoractivityreferredtoinScheduleB.
OR
(B) Mychild,orI,anIndependentStudentundertheSchoolAct(theStudent),willbegiventheopportunitytoparticipateintheprogram
andseriesofoffsiteactivitiesfortheprogramreferredtoinScheduleB.

1. AstheparentorlegalguardianoftheStudent,IagreeonmyownbehalfandonbehalfoftheStudent(or,asanIndependentStudent,Iagree)
toreleaseTheCalgaryBoardofEducation(CBE),itsTrustees,Superintendents,employees,consultants,agentsandvolunteers(collectively,
theCBEGroup)andtheServiceProvider(s)oftheprogramoractivitynamedinScheduleBandits/theirrespectivedirectors,officersand
personnel(togetherwiththeCBEGroup,collectively,theReleasees)fromanyactions,claims,demands,losses,liabilities,damages,costs
andexpenses(Losses)arisingfromorrelatedto:
a) theprogramandactivity/iesandanyservicesprovidedtotheStudentduringtheprogramandactivity/ies,excepttotheextentofLosses
arisingfromthenegligenceorwilfuldefaultofanyoftheReleasees
b) anyrisksandhazardsinherentinorarisingfromtheprogramandactivities,whetherforeseeableorunforeseeable
c) anydelayorfailuretoperformtheprogramoractivity/iesorrelatedservicesarisingduetoeventsbeyondthereasonablecontrolofthe
Releasees,includingwithoutlimitation,asaresultofactsofGod,fire,flood,epidemic,earthquake,terroristacts,actsofwar,governmental
actionsorchangesoflawand
d) transportationoftheStudenttoandfromtheactivity/ies,includinginthecourseofembarkingordisembarkingfromanymodeof
transportation.

2. IacknowledgethattheCBEshallusereasonablecommercialeffortstoensurethat:
a) thesupervisorsandstaffoftheServiceProviderarefullytrainedandqualifiedtosuperviseanddirecttheactivities
b) anyCBEteacherorpersonnelaccompanyingtheparticipantsduringtheprogramandactivitiesaretrainedandskilledasapplicable
c) thelocationand/orfacilitiesatwhichtheactivitiesarecarriedoutmeetapplicablehealthandsafetystandards
d) anyequipmentmadeavailabletotheStudentbytheServiceProviderforuseintheactivityhasbeeninspectedbyitandisdeemedbyitto
beappropriate,safe,andwellmaintained
e) theStudentwillbeaskedtoparticipateinactivitiesduringtheprogramoractivity/iesthatareageandobservableskillsappropriateand
f) theServiceProviderhastakenallreasonablestepstoensurethatanyanimal(s)involvedintheactivityaresafe.

3. a) IhavebeenprovidedbytheCBEwithinformationabouttheprogramandactivity/ies,includingthegeneralnatureofcertainforeseeable
risksandhazardsassociatedwiththeprogramandactivity/ies.HoweverIunderstandanysuchrisksthatmayhavebeenidentifiedbythe
CBEdonotconstituteacomprehensiveandexclusivelistofforeseeableorunforeseeablerisks.Iamnotrelyingsolelyuponsuch
informationprovidedbytheCBEandIreservetherighttoobtainadditionalinformationuponsuchbasisasIdetermine.
b) IvoluntarilyacknowledgeandassumeonmybehalfandonbehalfoftheStudent(orI,asanIndependentStudent,assume)therisksand
hazards,knownandunknown,inherentinthenatureoforarisingfromorrelatedtotheprogramandactivity/iesandIunderstandand
acknowledgethattheStudent(or,asanIndependentStudent),asaparticipantintheprogramandactivities,maysufferpersonaland
potentiallyseriousinjury,illness,propertydamageorlossduetotheforeseeableandunforeseeablerisksinherentinorrelatedtothe
programandactivity/ies.

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Consent and Acknowledgement of Risk


4. IconfirmthattheStudent(orI,asanIndependentStudent)shallcomplywiththeCBEspoliciesineffectfromtimetotime(ascontainedon
CBEswebsiteorasotherwisedisclosedtomebyCBE)andanyapplicableCBEorschoolCodeofConductandtherulesoftheService
Provider(asdisclosedtome)inrespectoftheprogramandactivity/iesaswellwiththedirectionsandinstructionsoftheCBEand/orService
Provider(s)withrespecttotheprogramandactivity/ies.

5. IacknowledgethatthefailureoftheStudent(ormyfailureasanIndependentStudent)toabidebytheCBEand/orServiceProvider
instructionsanddirectionsandwithanyapplicablelawsduringorrelatedtotheprogramandactivity/iesmayresultinexclusionoftheStudent
(orme,asanIndependentStudent)fromtheprogramandactivities,inwhichevent,I,asaparentorguardianwilltransporttheStudent(orI,
asanIndependentStudent,willberesponsiblefordeparting)fromthelocationoftheactivities.

6. IacknowledgethatitismyresponsibilitytoadvisetheCBEofanymedicalandhealthconcernsaswellasdietaryrestrictionsthatmayaffect
theStudentsparticipation(ormyparticipationasanIndependentStudent)intheprogramandactivity/iesandIconsenttothesharingofsuch
informationbytheCBEwiththeServiceProvider(s)andalloftheirrespectiveapplicablepersonnelandapplicableprofessionalmedical
personnelasreasonablyrequired.

7. IacknowledgeandagreethattheCBEand/ortheServiceProvidermaytakeanyactionstheydeemnecessaryfortheStudentssafety,health
andwellbeingand,inthecaseofamedicalemergency,mayseekprofessionalmedicaltreatmentand/ormaytransportorarrangetotransport
theStudent(ormeasanIndependentStudent)foremergencymedicalcare,atmyexpense.Schedule A to this Consent is a Medical
Information form that I shall complete, sign and return with this form to the CBEandIwarrantthattheinformationcontainedtherein
concerningtheStudentiscompleteanduptodate.

8. IunderstandthatIamresponsiblefortheStudents(or,asanIndependentStudent,my)illegalactivitiesarisingduringtheprogramand
activity/ies(includingtheft,vandalismorusingortraffickinginillegalsubstancesornonprescriptiondrugs).

9. IconfirmthatthisConsentshallbebindinguponmeand,ifIamaparent/legalguardianofaStudent,thatitshallalsobindtheotherparentor
legalguardianoftheStudentandtheStudentsothatiftheotherparentorlegalguardianortheStudentshallcommenceanyactionorclaim
againstanyoftheReleaseesinrespectofthemattersherein,IindemnifytheReleaseesfromanyLossesarisingtherefrom.

10. IconfirmthatIhavehadtheopportunitytoseekindependentlegaladvicepriortosigningthisConsent.


Signature:(Parent/GuardianorIndependantStudent)

PrintName

ContactTelephoneNumber

Date

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Schedule A
IMPORTANT Medical Information

Health Information: (Teacher will have a photocopy of this information during the OffSite Activity/ies to address health and medical
needs including emergencies and may share this information with others as deemed necessary.) Can be typed or handwritten MUST BE
COMPLETED BY A PARENT, GUARDIAN OR INDEPENDENT STUDENT
Activity:NationalMusicCentreFieldTripWordstoSong&Kimball Date(s):
Performance
StudentName:
DateofBirth(yy/mm/dd):

DrugAllergies? NoYesSpecifics/Severity:

FoodAllergies? NoYesSpecifics/Severity:

InsectAllergies? NoYesSpecifics/Severity:

OtherAllergies? NoYesSpecifics/Severity:

Isthestudentunderanyformoftreatmentforanillness, Yes Ifyes,pleaseelaborate.Includeactivitiestoberestrictedormodified.


conditionorinjury?(includingAsthma) No

Pleasefilloutthemedicationnamesanddetailsforadministeringthem:(ifmorespaceisrequiredpleaseattachadditionalinformation)

NAME OF MEDICATION REASON (OPTIONAL) DOSAGE HOW OFTEN? TIME OF DAY




Medicationstoragerequirements:

Arethereanyknownsideeffectstoabovemedication(s)?Ifyes,pleasedescribe:

Doesthestudenthaveanypsychologicaloremotionalproblems?Ifyes,pleasedescribe:

Arethereanyrecentinjuriestobeconcernedabout?Ifyes,pleasedescribe:

MedicalTreatmentRestrictions(ifany)e.g.bloodtransfusions:

DietaryRestrictions(ifany):
AdditionalInstructions/Information:
Emergency Contact 1: Emergency Contact 2:
Name: Name:

Home: Home:

Mobile: Mobile:

Work: Work:

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IncompliancewithTheCalgaryBoardofEducation(CBE)AdministrationRegulation6002,parents/legalguardians/IndependentStudentsare
responsibleforprovidingmedicalsupportsandmedicationprescribedforthestudentbyaphysicianormedicalprofessionaltoensurethestudent
hasthesupportsandmedicationrequiredwhileatschoolorduringoffsiteactivities.TheCBE,itsteachersandstaffwillnotadministerthe
medicationorsupportsbutduringschoolactivities,shallstorethemedicationandsupportsandsupervisethestudentinselfmedicating.The
parent/legalguardian/IndependentStudentshallnotifytheTeacherofthenatureofthemedicationandsupports,thetimingofselfmedicationand
anyproceduresthatapplytosame.

If the student is registered in a CBE High School,therequirementofteacher/staffsupervisionofselfmedicationbythestudentandofstoring
medicationmaybewaivedbytheparent/legalguardian/IndependentStudentbymarkingintheboxbelowwithanX:

IdonotwishtheCBE,itsteachers/stafftostorethestudentsmedicationorsupervisetheselfmedicationbythestudent.

Pleasenotethat:
1. theprovisionscontainedinthisformaresubjecttotheCBE'sAdministrativeRegulation6002,asamendedfromtimetotime(availableforview
ontheCBEwebsite)andapplicablelawsand

2. theprovisionscontainedinthisformfurtheraresubjecttotheapplicableschoolsEmergencyResponseProtocolandanyparticularStudent
HealthPlancompletedbytheCBEwiththeparent/legalguardian/IndependentStudent.

Notwithstandinganyoftheforegoing,Iagreethatthemedications(prescription/nonprescription)listedonthefirstpageofthisformarethe
studentsresponsibilityandthestudentisresponsibleforhowthemedicationisstoredandwhenitistaken.I,theparent,legalguardianor
IndependentStudent,acceptresponsibilityinallcasesforanymedicationthatislost,stolenordamaged.IconfirmthattheTeacherhasbeen
informedaboutthenatureofthemedication(s),knownsideeffectsandconsequencesofmisseddosesorextradosesandanyotherpertinent
medicalinformationbyme.

To the best of my knowledge, the medical information contained in this form is accurate and up to date and I shall inform the Teacher
immediately of any changes to such information. I understand the risks involved in the taking of such medications by the student prior to
or during the offsite activity or trip in which the student shall be a participant. I further agree to the following:

a) in the event of a medical emergency involving the student, the Teacher or his/her designates and any applicable CBE personnel or the
Service Provider service provider may seek immediate professional medical assistance and CBE may disclose the information
concerning the medications and all other relevant personal information concerning the student to professional medical advisors or
paramedics as reasonably required and
b) if the medications are missing or damaged during the course of the offsite activity or trip, I release the CBE and any offsite service
provider and its and their respective personnel, trustees, directors, officers, employees, consultants, agents, volunteers and
representatives from any claims, actions, losses, damages, liabilities and costs arising therefrom.


Date Name(pleaseprint) Signature(Parent/LegalGuardian/Independant
Student)

PersonalinformationiscollectedundertheauthorityofAlbertasFreedomofInformationandProtectionofPrivacyAct(FOIP)andtheSchoolAct.Thisinformationwillbeusedtoseeifthecandidate(s)meet
thecriteriaandwillbetreatedinaccordancewiththeprivacyprotectionprovisionsoftheFOIPAct.Ifyouhaveanyquestionsaboutthecollection,contactyourSchoolPrincipalorCorporateRisk
Managementat(403)8177404.

CAN:20964904.3

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Schedule B: Program/Activity Information

TeacherInCharge: Ross,KathleenA
ServiceProvider(s): NationalMusicCentre

Activities
Departure Return
Activity Location/Destination
(dd/mm/yy) (dd/mm/yy)
NationalMusicCentreFieldTripWordstoSong&Kimball StudioBell8504StreetSECalgary,ABT2G 13/04/17 13/04/17
Performance 1R1

Risks/Hazards
Source Risk
Entiretrip Slips,tripsandfalls
Entiretrip Gettinglostorseparatedfromthegroup
Entiretrip Preexistingmedicalconditions
Entiretrip Weatherconditions
TransportationVehicle Mechanicalfailure
TransportationVehicle PoorDrivingConditions
TransportationVehicle Delay
TransportationVehicle Accidents
Eating Allergies
Eating Choking

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