Ridgecliff Middle School
Telephone: 902 – 876 - 4381
Fax Number: 902 – 876 - 4385
35 Beech Tree Run
Beechville, NS B3T 2E5
rms@staff.ednet.ns.ca
Mr. Jamie Moore (Principal)
Mr. Sohael Abidi (Vice-Principal)
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Grade 9 Trip 2016 - Application & Health Information
CONTACT INFORMATION:
Student Name: ________________________________________________________
Student Cell #: _______________________
Address: _______________________________________________________________________ Postal Code: _______________
(Contact 1) Parents/Guardians: ________________________________________________________________________________
Home #: ___________________________
Work #: _____________________________
Cell #: ______________________
(Contact 2) Parents/Guardians: ________________________________________________________________________________
Home #: ___________________________
Work #: _____________________________
Cell #: ______________________
Please provide at least one parent/guardian email address for monthly statement reminders, trip information and fundraising information.
If you do not have access to email, please let us know so a paper copy can be provided.
Parent/Guardian email address:
____________________________________________________________
Parent/Guardian email address:
____________________________________________________________
Student email address:
____________________________________________________________
IDENTIFICATION:
Valid Passport:
____ yes _____ no
If yes, please write the name and expiry date as specified on the passport
_____________________________________________________________________________
_____/______/_____
Day/month/year
If no, please write the name and expiry date as specified on a, government issued identification
_____________________________________________________________________________
_____/______/_____
Day/month/year
A passport is NOT necessary to fly within Canada so if your child does not already have a passport,
a government issued identification, can easily be obtained at Access NS for approximately $20.
Please see more information at http://www.gov.ns.ca/snsmr/rmv/other/idcard.asp
MEDICAL:
Provincial Health Card #: ________________________________ Expiry Date: ____/_____/____
Date of Birth: ____/_____/____
Day/month/year
Day/month/year
Family Doctor: ________________________________________ Phone: ___________________________
Does your child have any potential life threatening medical conditions? If yes, please specify.
Please specify any medications as well as medical response and instructions that may be necessary.
Please list anything else we should know about your child. (diet concerns, sleep walking, allergies, etc.)
In the event that emergency medical treatment is required, I hereby give consent for my
son/daughter ____________________________________ to be treated by the attending physician.
Emergency Contact _____________________________________ __________________________
Name
______________________
Relationship
Parent/Guardian Signature:__________________________________________
Phone Number
Date:______________________
STUDENT ACKNOWLEDGMENT – I am a participant in the Ridgecliff Middle School’s Grade 9 Trip to Toronto, on Wednesday, June 1st to
Saturday, June 4th and agree to all of the following conditions:
The trip organizers, group chaperones, staff of Ridgecliff Middle School, and the Halifax Regional School Board shall not be liable for any
damages or loss to my person or property arising from my participation in this program. The trip organizers and/or group chaperones may
make reasonable changes in the itinerary for the mutual benefit and safety of group participants. In such event, they shall not be liable for any
delay, loss or damage that result. In the event of any illness, accident, or incapacity incurred by me, the group chaperones may consider my best
interests in securing medical treatment, hospitalization, medication and/or return transportation at my own expense. Any and all claims,
obligations, suits in any liabilities whatsoever against the organizers, chaperones, and/or the School Board are hereby waived and released. I
certify that I have read and understood this release and agree to abide by its provisions.
___________________________________
__________________________
Student Signature
Date
PARENT ACKNOWLEDGEMENT - I certify that I am the parent or legal guardian of the student named above and that I have read the foregoing
release. I allow my child to participate in this trip. I agree to every part of this release and hereby relinquish any claim that I may have against
the program organizers, chaperones, and the Halifax Regional School Board, both on my behalf and in my capacity as legal representative, while
my child is a participant in this program.
_________________________________
________________________________
Parent/Guardian Name (please print)
Parent/Guardian signature
____________________
Date