FORM 230-3B Adopted Last Revised Review Date April 2005 May 2015 May 2020 ATHLETICS TRIP INFORMATION AND CONSENT School: ______________________________ Telephone #: ____________________ After Hours: _____________________ Dear Parent or Guardian: Your child indicated an interest in the following inter-school athletics event. There are many benefits to participation in athletics. The program is designed to contribute to the student’s development of physical fitness and skills, teamwork and enjoyment of physical activity. Supervised instruction is part of the student’s preparation. Teacher / Supervisor(s): ___________________________________ Volunteers: _______________________________________ Type of Activity: _____________________________________________________________________________________________ Means of Transportation: (Bus Company & Number, Volunteer Drivers) _________________________________________________ For Single Activity: Destination: ______________________________________________________________________________ Departure Date: ____________________ Time: _______________ Return Date: ________________ Time: _______________ Cost Per Student: ___________________ Payment Due Dates: _________________ Refund Policy: _______________________ A tentative schedule of dates and locations is attached. Team schedules may be subject to change as a result of information not yet available. The student’s participation may include exhibitions, playoffs and tournaments not listed here. The school will inform students and their parent/guardian(s) of changes which occur. Any overnight trips will require a separate consent. ----------------------------------------------------Please return the bottom portion of this form--------------------------------------------------------------Medical and Emergency Information Update Student Name: ______________________________ Parent / Guardian Name: _______________________________________ Parent / Guardian Phone: _______________ 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 No Is there any medical background which might affect this student’s comfort or safety during this activity? Please check either: Yes or No Some trips may extend beyond normal school hours. Will your child require any medication 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, 322-2 and 322-3 as required). __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Form 230-3B Athletics Trip Information and Consent Page 1 of 2 Athletics Trip 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 school. -----------------------------------------------------------------Please return the bottom portion of this form--------------------------------------------------------------Destination: _______________________________________Date: _____________________Student Name:____________________________ ELEMENTS OF RISK NOTICE The risk of injury exists in every athletic 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 athletic 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 230-3B Athletics Trip Information and Consent Page 2 of 2
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