FORM 230-14 Adopted Last Revised Review Date April 2005 May 2015 May 2020 SECONDARY HEALTH AND PHYSICAL EDUCATION CONSENT TO PARTICIPATE IN ACTIVITIES OFF SCHOOL PROPERTY School: _________________________________________________ Date: _____________________________________________ Teacher: ________________________________________________ Course: ____________________________________________ Dear Parent/Guardian: Our Health and Physical Education/Healthy Active Living program may take your son/daughter off of the school grounds and into the community. If any activity is considered “High-Care” a separate consent form will be sent home with detailed information about required equipment and elements of risk. Regular, supervised components of our program that occur off school grounds and into the community include: Activity Location Time frame (when) MEDICAL AND EMERGENCY INFORMATION UPDATE Student Name: _____________________________________________________________________________________________ Parent/Guardian Name: _______________________________________________________________________________________ Parent/Guardian Phone #: ___________________________________ Work #: ________________ Cell #: ____________________ Alternate Emergency Contact Name: ___________________________ Phone #: _________________________________________ Family Doctor: _____________________________________________ Doctor’s Phone #: __________________________________ I give consent for the teacher/supervisor to seek emergency medical care for my child if needed and I understand that the school will attempt to contact me in case of medical or other emergency. Please check either Yes or No Is there any medical background which might affect this student’s comfort or safety during this activity? Please check either Yes or No Please give details of any medical history (including previous concussion(s), needs and/or medication below. If necessary, contact the student’s teacher/supervisor at the school to discuss (teacher/supervisor will review Forms 230-9, 230-10, 230-11, 322-1, 322-2 as required) Form 230-14 Secondary Health and Physical Education Consent to Participate in Activities off School Property Page 1 of 2 ELEMENTS OF RISK NOTICE The risk of injury exists in every out of school activity. Falls, collisions and other incidents may occur and cause injury. Due to the very nature of some activities, the risk of injury may increase. Injuries may range from minor sprains and strains to more serious injuries affecting the head, neck or back (i.e., concussion). Some injuries can lead to paralysis or prove to be life-threatening. These injuries result from the nature of the activity and can occur without fault on either the part of the student, or the school board or its employees or agents or the facility where the activity is taking place. The chances of an injury occurring can be reduced by carefully following instructions at all times while engaged in the activity. The Hastings and Prince Edward District School Board attempts to manage as effectively as possible the risk involved for students while participating in school athletics. Examples of risk in this particular activity are: ACCIDENT INSURANCE NOTICE The Hastings and Prince Edward District School Board does not provide any accidental death, disability, dismemberment or medical expenses insurance on behalf of student’s participating in these activities. Parents/Guardians and students are advised that it is their responsibility for additional health and accident insurance. Students planning to participate in athletic activities and events during the school year are advised to purchase Student Accident Insurance. To purchase Student Accident Insurance, contact the school office. I understand and accept the expectations listed above. ______________________________ _____________________ Student’s Signature Date I have read and understand the Elements of Risk Notice and the Accident Insurance Notice. I hereby acknowledge and accept the risk inherent in the requested activity and assume responsibility for my child for personal health, medical, dental and accident insurance coverage. I agree that the Hastings and Prince Edward District School Board or its employees, servants or agents shall not be liable for an injury to my child or loss or damage to personal property arising from, or in any way resulting from participating in the above listed activities. I consent to this student’s participation in the learning activity. ______________________________ Parent/Guardian Signature _____________________ Date This information is collected under the authority of the Education Act and in compliance with the Municipal Freedom of Information and Protection of Privacy Act. It will be used for the purpose of athletic activities. If you have any questions about this form, please contact the principal at the School. Form 230-14 Secondary Health and Physical Education Consent to Participate in Activities off School Property Page 2 of 2
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