CORNERSTONE YOUTH CENTRE
Consent of Parent and/or Guardian and “Acknowledgement of Risk” for “A”
and “B” On-Site and Off-Site Activities
Medical Information for all Cornerstone Activities
Student First Name: ________________________ Last Name:
______________________________
My child will be given the opportunity to participate in the following program or activity:
Purpose of the Trip: Annual Summer Trip to Calaway Park
Service Provider: Calaway Park Destination: Calaway Park, 245033 Range Rd 33, Calgary, AB
Departure: 12:30pm Arrival: 6:00pm Employee in Charge: Courtney Gimblett
Cornerstone will make commercially reasonable efforts to ascertain that:
a.
Supervisors and Staff of the Service Provider are fully trained and qualified
b.
Youth who undertake the program or activities will be adequately supervised
c.
Location and/or facilities meet the applicable health and safety standards
d.
Equipment made available by the Service Provider or used in the activity has been inspected
and deemed to be appropriate, safe, and well maintained
CONSENT AND AKNOWLEGMENT OF RISK
Activity:
Risk/Hazard (Cause of Injury) Examples:
Entire Trip:
Slips, trips, falls, getting lost or separated from the group, pre-existing medical
conditions, horseplay
Eating:
Choking, allergies
Transportation: Poor driving conditions
Site:
Fire and evacuation, unfamiliar environment
TRANSPORTATION INFORMATION
Transportation method: Vehicle
Driver(s): Lance & Tanya Hofer and Courtney Gimblett
I accept this/these mode(s) of transportation for this activity: Yes ____ No ____
OR
I permit my child to use alternate means of transportation, as identified:
Yes ____ No ____ Other: ___________________________________(please specify)
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I am satisfied that I have been informed of my right to obtain as much information about this program,
or activity as I feel necessary, including information beyond that provided to me by Cornerstone Youth
Centre (Cornerstone) to the extent that I require and I am not, in any way, relying solely upon
information provided by Cornerstone respecting the nature and extent of the risks and hazards
associated with the program or activity.
I freely and voluntarily assume the risks and hazards inherent in the nature of the program or activity
and understand and assume the risks and hazards inherent in the nature of the program or activity and
understand and acknowledge that my child as a participant, may suffer personal and potentially serious
injury, illness or death due to an unforeseeable or fortuitous event.
My child has been informed that he/she is to abide by the rules and regulations including directions and
instructions from the Cornerstone employees and volunteers, instructors, and supervisors as imposed
on youth participating in the program or activities. This shall include his/her participation in all of the
introductory sessions and meeting all prerequisites prior to his/her participation in the activity or
program.
In the event that my child fails to abide by the rules and regulations imposed on the students while
participating in the program or activities, Cornerstone may determine that he/she may not participate
in the program or activity, or Cornerstone may require that I have him/her picked up, unless I have
permitted my child to pursue alternate means of transportation as identified herein.
I knowledge that it is my responsibility to advise Cornerstone of any medical or health concerns of my
child which may affect his/her participation in the stated program or activity.
I consent that Cornerstone (through its employees, consultants, and agents) may secure such medical
advice and service as Cornerstone, in its sole discretion, may deem necessary for my child’s health and
safety, and I shall be financially responsible for such advice and services.
Based upon my understanding of the activity(ies) and the hazards identified above, I give my child
permission to participate in this activity(ies).
I have read discussed the risks and expectations of the activity with my child and have confidence that
my child has understood them.
Signature (Parent/Guardian):____________________________________
Name (Please Print): __________________________________________
Date: ______________________
ALBERTA HEALTH CARE:
Health information: Supervisor-in-charge will have a copy of this information during the off-siteactivity to address health and medical needs including emergencies and may share this information
with others as deemed necessary.
Health Care Number (optional): _______________ Date of Birth: __________________
Allergies:
*If yes, please specify below and include SEVERITY*
Drug Allergies? Yes____ No____ Specifics: ___________________________________________
Food allergies? Yes____ No____ Specifics: ___________________________________________
Insect Allergies? Yes____ No____ Specifics: ___________________________________________
Other Allergies? Yes____ No____ Specifics: ___________________________________________
Medical Conditions:
Is your child under any form of treatment for an illness, condition, or injury?
Yes____ No____ If yes, please elaborate, include activities to be restricted or modified:
____________________________________________________________________________________
Please fill out any medication name(s) and details for administering them:
(If more space is required please attach additional information)
Name of Medication: ______________________ Reason: __________________________________
Dosage: _______ How often: _______ Time of Day: ________ Storage requirements: _________
Does the youth possess any psychological or emotional problems?
____________________________________________________________________________________
Are there any recent injuries to be concerned about? If yes, please describe.
____________________________________________________________________________________
Medical Treatment Restrictions, if any (i.e. Blood transfusions): ____________________________
Dietary Restrictions, if any: ___________________________________________________________
Additional instructions/information: ___________________________________________________
___________________________________________________________________________________
EMERGENCY CONTACTS:
Emergency Contact #1:
Name: ____________________ Relationship: __________ Home: _________ Mobile: __________
Emergency Contact #2:
Name: ____________________ Relationship: __________ Home: _________ Mobile: __________
SIGNATURE FOR CONSENT:
MEDICAL CONSENT
The above MEDICAL INFORMATION is accurate to the best of my knowledge. I hereby give
Cornerstone Youth Centre staff and representatives permission to assist and administer the above
medications. I am fully aware of these medicines’ effects and side effects and understand the risks
involved with my child taking them during Cornerstone activities. Taking these medicines will not
inhibit, alter, or prevent my child’s performance during the activity.
I hereby consent to the following medicines and dosages to be given to my child at the following times
of day under these circumstances. I am aware that, under extraordinary circumstance, the medicines
may become lost, stolen, or damaged. In these circumstances, I will not hold the supervisor in charge
liable to replace lost medicines.
________________________________
SIGNATURE (parent/guardian)
_______________________________________
NAME (please print)
Date: __________________________
PHOTO CONSENT
I am aware that photographs, videotape, and digital recordings may be taken at the Centre and
outside of the Centre, during program or activity hours, and used for promotion of the Cornerstone
Youth Centre in various media forms, including Website, Twitter, and Facebook. I consent to the use
of my likeness, and understand that I can revoke my consent at any time.
________________________________
SIGNATURE (parent/guardian)
Date: __________________________
_______________________________________
NAME (please print)