FORM 230-2
Last Revised
Review Date
April 2005
May 2015
May 2020
School: _________________________________ School Phone #: __________________ After Hours #: ______________________
Type of Excursion:
Same Day Ontario/Quebec
Extended / Overnight
High-Care Activity
Teachers/Supervisors: ________________________________________________________________________________________
Means of Transportation: (Bus Company & Number, Volunteer Driver Names)
Destination: ________________________________________________________________________________________________
Departure Time: _____________ Date: ______________________ Return Time: ____________ Date: _____________________
Cost Per Student: ____________ Payment Due Date: ____________________________ Refund Policy: ______________________
Special Clothing or Food Required for Excursion: ___________________________________________________________________
----------------------------------------------------Please return the bottom portion of this form----------------------------------------------Medical and Emergency Information Update
Student Name: _________________________________ Parent / Guardian Name: ______________________________
Parent/Guardian Phones Home: ________________ Work: _______________ Cell: ___________________________
Alternate Emergency Contact Name: ___________________________________ Phone #: ________________________
Family Doctor: _____________________________________________________ Phone #: _______________________
I give consent for the teacher/supervisor(s) to seek emergency medical care for my child if needed and I understand that the school
will attempt to contact me in case of a medical or other emergency.
Please check either:
Yes or
Is there any medical background which might affect this student’s comfort or safety during this activity?
Please check either:
Yes or
Some trips may extend beyond normal school hours. Will your child require any medication during this activity?
Please check either:
Yes or
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, 322-11, 322-2 as required)
Form 230-2 Parent Information and Consent to Participate
Page 1 of 2
Purpose of the Excursion in Relation to School Program: ____________________________________________________________
Pre-Excursion Learning Activities: _______________________________________________________________________________
Learning Activities during Excursion: _____________________________________________________________________________
Post-Excursion Learning Activities: ______________________________________________________________________________
Expectations of Students:
To participate in any Out-of-School Learning Activity, a student must accept the rules of the
school and of the group in order to enjoy the benefits that are offered.
In order to participate, each student must:
1. Submit in advance a properly signed trip consent form.
2. Understand that he/she is subject to all usual school rules and consequences during all trips and behave accordingly.
3. Understand that he/she must follow the teacher/supervisor’s instructions from departure to return to the school.
4. Know that specific excursion rules may be made by the teacher and approved by the Principal and communicated to
students and parent/guardian(s) prior to the trip.
5. Understand that in additional to usual school rules and consequences, failure to follow trip rules may result in a
parent/guardian being called and the student sent home from the activity, and/or not allowed to participate in
similar activities for a period of time.
6. Understand that he/she may not leave the school group without permission from the teacher-supervisor.
7. Understand that he/she must use the transportation arrangements agreed to by the parent/guardian and school
authorities (including the person who will pick up the student at the return point.
8. Know that, smoking and the use of alcohol and non-prescription drugs are forbidden on all school trips as they are at
---------------------------------------------------------------------Please return the bottom portion of this form--------------------------------------------------------------Destination: ___________________________________Date: ________________ Student Name:______________________________________
The risk of injury exists in every 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
Examples of risk in this particular activity are:
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 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
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
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 230-2 Parent Information and Consent to Participate
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