ROBERT F. HALL C.S.S.
WOLFPACK ATHLETICS
This form is to be completed on behalf of a student who wishes to participate in interschool activities and returned to the coach/teacher prior to the student’s first tryout.
Dear Parent(s)/Guardians/Adult Student:
Vigorous physical activity is essential for normal, healthy growth and development. Growing bones and muscles require not only good nutrition, but also the stimulation of vigorous physical activity to increase
the strength and skills necessary for a physically active lifestyle. Active participation provides opportunities for students to discover and trust themselves and gain the confidence necessary to play and work
cooperatively and competitively with their peers. Participation in interschool activities provides opportunities for students to experience the fitness feeling and to help them understand and make decisions
regarding personal fitness and the value of physical activity in their daily lives. Interschool activities may take place either at school or at an out-of-school location.
It is important that your son/daughter participate safely and comfortably in the interschool activity. The Dufferin-Peel Catholic District School Board adheres to the Ontario Physical and Health Education
Association (OPHEA) Guidelines. In your child’s best interests, we recommend the following:
a) An annual medical examination;
b) Appropriate attire and footwear for safe participation;
c) Hanging jewelry must not be worn. Jewelry which cannot be removed and which presents a safety concern must be taped;
d) The wearing of an eyeglass band and/or shatterproof lens if your child wears glasses which cannot be removed during interschool activities;
e) The wearing of sun protection for all outdoor activities;
f) Safety inspection at home of any equipment brought to school for personal use, must meet appropriate certification, e.g. Canadian Standards Association (CSA) approved.
STUDENT INFORMATION AND POWER OF ATTORNEY
Name of Student: ______________________________________________ Age: _____ Date of Birth: ___________________ Sex: ______
Parent/Guardian:
___________________________________________________
Work Phone #:__________________________
Home Address: _______________________________________________________
Home Telephone: _________________________________
__________________________________________________
Family Doctor: ___________________________ Telephone: ___________________ Student Health Card Number:___________________
Emergency Contact: ________________________ Phone #: _________________________
MEDICAL INFORMATION
1. What medication(s) should your son/daughter have on hand during the interschool activity?
___________________________________________________________________________________________________________
2.
Is your son/daughter/ward allergic to any drugs, foods or medication/other? Yes _________ No _________ If yes, provide details:
___________________________________________________________________________________________________________
3.
4.
Does your son/daughter/ward wear a medical alert bracelet _______, neck chain _____ or carry a medical alert card? _____________?
Please indicate if your son/daughter/ward has been subject to any of the following and provide pertinent details: epilepsy; diabetes; orthopedic problems; deaf;
hard of hearing; asthma; allergies; head and/or back conditions or injuries (in the past two years); arthritis or rheumatism; chronic nosebleeds; dizziness; fainting;
headaches; hernia; swollen or hyper mobile joints; trick or lock knee:
Please provide any medical condition that will require modification of the program. All information will be held in the strictest confidence.
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Should your son/daughter/ward sustain a concussion or an injury requiring medical attention during the competitive season, notify the coach and
complete the “Request to Resume Athletic Participation Form”, if applicable.
ELEMENTS OF RISK: Educational activity programs, such as sporting events or activities, field trips and activities, may present various elements of risk.
Incidents related to such activities may occur and cause injury through no fault of the school board or the facility at which the activity or event is being held.
Participant must assume these risks.
The following interschool activities including and not limited to are identified as having the potential for more serious consequences are: Alpine
skiing/snowboarding, broomball (ice), cheerleading (acrobatic), field hockey, field lacrosse, gymnastics, ice hockey, ringette (ice), swimming,
wrestling, football and/or field events: high jump, shot-put. The safety and well-being of students is a prime concern and attempts are made to
manage, as effectively as possible, the foreseeable risks inherent in physical activity. Please contact the school to discuss any sport specific safety
concerns related to this activity.
By choosing to participate in the activity, you are assuming the risk of an injury occurring. The chances of an injury occurring can be reduced by carefully
following instructions at all times while engaged in the activity. The Dufferin- Peel Catholic D.S.B. attempts to manage as effectively as possible the risk involved
for students while participating in school athletics.
INTERSCHOOL ACTIVITY: VARSITY BOYS FOOTBALL
□ I acknowledge the element of risk information noted above for the interschool activity.
Signature of Parent/Guardian ______________________________________________
Date ______________
Signature of Student __________________________________________________________
Date _______________
NOTE TO STUDENT/PARENT(S)/GUARDIAN(S): The Dufferin-Peel Catholic D.S.B, does not provide any accidental death, disability, dismemberment or
medical expenses’ insurance on behalf of the students participating in these activities. The Dufferin-Peel Catholic District School Board distributes Student
Accident Insurance to the Parent/Guardian/Student, annually. For your information the following website has been provided: www.insuremykids.com
□ I acknowledge that the Dufferin-Peel Catholic District School Board does not provide accident or life insurance for students.
□ I acknowledge that I have received a copy of the student accident insurance brochure.
________________________
____________
__________________________________________
___________________
(Signature of Student)
(Date)
(Signature of Parent/Guardian/Adult Student)
(Date)
PERMISSION: We, the parents/guardians of ______________________, consent to our child’s participation in the FOOTBALL TEAM Program from
JUNE 2015 to NOVEMBER 30, 2015.
__________________________________________
(Signature of Parent/Guardian/Adult Student)
___________________
(Date)
MEDICAL SERVICES AUTHORIZATION
Every reasonable effort will be made by the school/hospital to contact me. Should it become necessary for our son/daughter to have medical care, I/we hereby give the teacher permission to use
her/his best judgement in obtaining the best of such service for our son/daughter. We understand that any cost will be our responsibility. In case of emergency medical or hospital services being
required by the above listed participant, and with the understanding that every reasonable effort will be made by the school/hospital to contact me, my signature on this form authorizes medical
personnel and/or hospital to administer medical and/or surgical services including anesthesia and/or drugs. I understand that any cost will be my responsibility.
Signature of Parent/Guardian/Adult Student: ___________________________
(cell) ___________________ Date: _______________________________
PHOTO RELEASE
Photographs of participants may be taken at any time for local and GTA high school reports. Do you give permission for your child to be interviewed and/or be photographed
staff or the local media?
Signature of Parent/Guardian: _______________________________________ Date: ________________________
MUNICIPAL FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY ACT: Personal information on this form is collected under the legal authority of the Education Act, R.S.O. 1990, cE.2. as
amended. This information will be used for purposes of planning and administering Physical Education programs for students and providing health and safety services in the event of an emergency.
Questions regarding the collection of personal information are to be directed to the School Principal.
THE DUFFERIN-PEEL ROMAN CATHOLIC SEPARATE SCHOOL BOARD
PARENTAL/GUARDIAN PERMISSION TO TRANSPORT SELF OR OTHERS
IN A PRIVATE AND/OR COMMERCIAL VEHICLE –SECONDARY STUDENTS
NOTE: Only Applies to School Approved Student Activities/Excursions
DATE: _________________________
DEAR PARENT/GUARDIAN OF: _________________________________________
Description of Activity: Wolfpack Football Team – September 2015 – November 2015
Due to the nature of some activities, they are unavailable to be offered at the school, Robert F. Hall C.S.S. It will, therefore, be necessary for the
students to travel to other facilities off of school property. Transportation to these facilities will be accomplished in one of four ways. Some students
will travel via the school van and/or bussette, a Board-approved taxi, some via a personal vehicle driven by a Board-approved adult (such as a staff
member or a non-student volunteer), while other students may choose to drive themselves.
The Board does not approve students driving other students to Board/school sanctioned activities. It is because of this situation that we ask you to
read and sign the appropriate section(s) below: (Please sign all sections which pertain to your child)
1. I hereby give permission for my child to drive himself/herself to and from the activities described above:
Parent/Guardian Signature: __________________________________
2. I hereby give my permission for my child to ride in a private car, driven by the teacher or another Board-approved adult (nonstudent) volunteer, to and from the activities described above.
Parent/Guardian Signature: ____________________________________
3. My child may ride in the school van/busette to and from the activities described above.
Parent/Guardian Signature: ____________________________________
4. My child may ride in a Board approved taxi to and/or from the activities described above, whether or not there is a teacher and or adult
supervisor.
Parent/Guardian Signature: ____________________________________
I understand that all activities, including the transportation of my child, have some inherent danger and I accept the risks and dangers. I understand also that the Dufferin-Peel
Catholic District School Board will provide transportation for my child and that if my child elects to drive, she/he does so at her/his own risk, my child is not authorized by to
the Board to transport other students, and that my child is covered under my automobile insurance policy.
Signature of Parent/Guardian: _______________________________________ Date: ________________________
MUNICIPAL FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY ACT: Personal information on this form is collected under the legal authority of the Education Act, R.S.O. 1990, cE.2. as
amended. This information will be used for purposes of planning and administering Physical Education programs for students and providing health and safety services in the event of an emergency.
Questions regarding the collection of personal information are to be directed to the School Principal.