REGISTRATION FORM
FOCUS ON YOUTH SUMMER CAMP
FOR DUFFERIN-PEEL CATHOLIC DISTRICT STUDENTS GRADES 6-8
Thank you for deciding to register for the Focus On Youth Summer Camp. Focus
on Youth is funded by the Ontario Ministry of Education to support non-for-profit
groups in delivering summer programs that keep young people safe and active.
The Dufferin-Peel Catholic District School Board and Lost Lyrics have partnered to
deliver a unique summer experience for youth.
The Lost Lyrics summer arts program will engage and empower youth through
artistic expression to be role models and leaders in their community. This program
will explore themes of student empowerment through the artistic channels of rap,
recording, photography, film and visual arts. While learning about student voice,
participants will also learn how to become leaders and role models by sharing
their unique voices and vision with the broader community.
NAME OF STUDENT
CURRENT SCHOOL
HOME ADDRESS
PHONE #
DATE OF BIRTH
GENDER
GRADE in September
(MM/DD/YY)
Please fill out all of the forms in this package and bring to the first day of the program. Your child will not be
allowed to participate without the signed complete package.
Please fill out all of the forms in this package and bring to the first day of the program. Your child will not be
allowed to participate without the signed complete package.
MEDIA CONSENT FORM
SCHOOL: Focus on Youth Summer camp at Ascension of Our Lord Secondary School
SCHOOL YEAR: Summer July –August 2014
To: Parent(s)/Guardian(s)/Adult Student:
From July 7th to August 8th, 2014 representatives from the DPCDSB, Local Media and Unity Charity will be in
attendance at the Focus on Youth Summer Camp at St. Monica Elementary School Brampton, ON, to
film/photograph/videotape or make an audio or digital recording of our students. The purpose, use and
disclosure of this collection of personal information is to:

Highlight the participation of Dufferin-Peel students as part of the ‘Focus on Youth Summer Camp”
_____________________________________________________________________________________________
Please be advised that all or portions of the work referred to above will become part of the media organization's
database and may be adapted for other educational or non-educational applications, productions, broadcast, rebroadcast, published, exhibited, reproduced, and/or distributed in various media formats to a number of markets.
Schools cooperate with the media and other organizations, within reason, to encourage celebration of school
achievements and the sharing of information about students and student work. However, we recognize that there are
instances where a parent/guardian/yourself may not wish their child/children/themselves recorded.
To: The Dufferin-Peel Catholic District School Board
I HAVE READ AND UNDERSTAND THE INFORMATION PROVIDED ON THIS FORM. I VOLUNTARILY GIVE THE DUFFERIN-PEEL
CATHOLIC DISTRICT SCHOOL BOARD CONSENT TO INCLUDE MY CHILD OR ME IN THE MEDIA COVERAGE AND ITS
SUBSEQUENT USE DISCLOSURE AS DESCRIBED ABOVE.
I further understand that this consent is valid for the current school year and may be withdrawn by me at any time, upon
written notice.
This Consent form meets the requirements of the Municipal Freedom of Information and Protection of Privacy Act and
the Education Act for the disclosure of personal information.
____________________________________
_______________________________________
Name of Student (Please Print)
School
____________________________________
_______________________________________
Name of Parent/Guardian
Signature of Parent/Guardian
____________________________________
Name of Adult Student (18 Yrs and Older)
_______________________________________
Signature of Adult Student (18 Yrs and Older)
___________________________________
Date
Communications & Community Relations Department
2012-2013 Media Consent Form
Please fill out all of the forms in this package and bring to the first day of the program. Your child will not be
allowed to participate without the signed complete package.
GF 403
ELEMENTARY INTERSCHOOL –
MEDICAL INFORMATION/ELEMENT OF RISK/PERMISSION TO PARTICIPATE
This form is to be completed on behalf of a student who wishes to participate in interschool sports and returned to the coach prior
to the student’s first tryout.
Dear Parent(s)/Guardian(s):
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 child 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 for safe participation (T-shirt, shorts or track pants and running shoes). Hanging jewelry must not
be worn.
c) The wearing of an eyeglass band and/or shatterproof lens if your child wears glasses which cannot be removed during
physical education classes.
d) The wearing of sun protection for all outdoor activities.
e) Safety inspection at home of any equipment brought to school for personal use in class.
STUDENT NAME ___________________________________________
TEACHER _____________________________
HOME ADDRESS ___________________________________________
GRADE _______________________________
HOME PHONE # ____________________________________________
PARENT/GUARDIAN ________________________________________
WORK PHONE # ________________________
EMERGENCY CONTACT NAME ________________________________
PHONE # ______________________________
I would like to inform the school about these facts pertaining to my son/daughter’s physical/medical condition related to
his/her participation in the Interschool activity:
1.
What medication(s) should your son/daughter have on hand during the interschool activity?
______________________________________________________________________________________________
2.
Does your son/daughter wear a medical alert bracelet_____ neck chain _____ or carry a medical alert card? ______
If yes, please specify what is written on it: ____________________________________________________________
3. Any other relevant medical condition that will require modification of the program: ___________________________
_______________________________________________________________________________________________
4.
Should your son/daughter sustain an injury or contact an illness requiring medical attention during the school year,
notify the coach and complete the “Request to Resume Athletic Participation Form”, as applicable.
(Revised April 2013)
If during the school year your son/daughter’s medical information profile changes, please notify the school.
ELEMENTS OF RISK: Educational activity programs, such as sporting events or activities, field trips and other 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, 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.
□
I acknowledge the element of risk information noted above for the interschool activity.
Parent/Guardian Signature:
_ Date:
____________
NOTE TO STUDENT/PARENT(S)/GUARDIAN(S): The Dufferin-Peel Catholic District School Board does not provide any
accidental death, disability, dismemberment or medical expenses’ insurance on behalf of students participating in these
activities.
The Dufferin-Peel Catholic District School Board distributes Student Accident Insurance to the
Parent/Guardian/Student, annually.
□
□
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)
(Date)
PERMISSION: I give permission for my son/daughter: ________________________________________ to participate in:
_____________________________
(Name of Interschool Activity)
______________________________________
(Signature of parent/Guardian)
______________
(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. We also understand
that in the event of illness or accident, we will be notified as soon as possible.
Signature of Parent/Guardian: __________________________________________ Date: ___________________________
Distribution to:
____ Parent/Guardian
____ Coach
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, c.E.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.
(Revised April 2013)
GF 401
ELEMENTARY HEALTH AND PHYSICAL EDUCATION CURRICULUM –
MEDICAL INFORMATION/ELEMENT OF RISK
This form is to be completed for all students and returned to the classroom teacher.
Dear Parent(s)/Guardian(s):
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. The physical education curriculum 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.
It is important that your child participate safely and comfortably in the physical education program. 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 for safe participation (T-shirt, shorts or track pants and running shoes). Hanging
jewelry must not be worn;
c) The wearing of an eyeglass band and/or shatterproof lens if your child wears glasses which cannot be
removed during physical education classes;
d) The wearing of sun protection for all outdoor activities;
e) Safety inspection at home of any equipment brought to school for personal use in class.
___________________
(Name of Student)
_______________
(Grade)
__________________________________
(Teacher)
I would like to inform the school about these facts pertaining to my son/daughter’s physical/medical condition related to
his/her participation in the Health and Physical Education Curriculum.
1.
What medication(s) should your son/daughter have on hand during health and physical education class? _________
2.
Does your son/daughter wear a medical alert bracelet ____ neck chain _____ or carry a medical alert card? ________
If yes, please specify what is written on it: _____________________________________________________________
3.
Any other relevant medical condition that will require modification of the program: ___________________________
________________________________________________________________________________________________
4.
Should your son/daughter sustain an injury or contact an illness requiring medical attention during the school
year, notify the classroom teacher and complete the “Request to Resume Athletic Participation Form”, as applicable.
If during the school year your son/daughter’s medical information profile changes, please notify the school.
ELEMENTS OF RISK: Educational activity programs, such as sporting events or activities, field trips and other 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. Participants must assume these risks.
The following class 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, 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.
Various health/physical education activities may take students into the immediate community to participate; e.g., inclass cross country running, orienteering, soccer, softball, etc., at nearby community parks.
□
I acknowledge the element of risk information noted above for the Health and Physical Education Curriculum.
Parent/Guardian Signature:
Date:
_____________
NOTE TO STUDENT/PARENT(S)/GUARDIAN(S): The Dufferin-Peel Catholic District School Board does not provide any
accidental death, disability, dismemberment or medical expenses’ insurance on behalf of students participating in these
activities.
The Dufferin-Peel Catholic District School Board distributes Student Accident Insurance to the
Parent/Guardian/Student, annually.
□
□
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)
_________
(Date)
Distribution to:
____Parent/Guardian
____Classroom Teacher
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, c.E.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.
(Revised April 2013)
GF 080
HEALTH AND SAFETY INFORMATION AND
MEDICAL CONSENT FORM
SCHOOL NAME: ________________________________________________________________________
Name of Student:
_____________________________________Sex: ____ Date of Birth: ____________
Address:
________________________________________________________________________
Parent(s)/Guardian(s) Telephone Number: Day________________________Night: ______________________
The following information will be helpful to the teacher in making your child’s out-of-school visit
more comfortable, safe and pleasant. All information will be held in the strictest confidence.
1.
Has your child any special conditions which must be taken into consideration in his/her
participation in the full program:
Allergy:
__________________ Rash:
________________
Diabetes:
__________________ Heart:
________________
Asthma:
__________________ Epilepsy:
________________
Feet or Legs:
__________________ Rheumatic Fever: _______________
Recent illness or operation: _______________________________________________________________
Any other medical concern, which the teacher would need-to-know:
______________________________________________________________________________________
2.
3.
4.
5.
Has your child any drug allergy or sensitivity: If so, please provide details:
______________________________________________________________________________________
Has your child any serum sensitivity? If , give details: _________________________________________
Give date of last tetanus shot and reason for it: ________________________________________________
If your child has any special night-time habits, any special fears or nervous peculiarities (e. g.
bed wetting, nightmares), knowledge of which will allow the teacher to make his/her visit
more relaxed, please state:
______________________________________________________________________________________
If it is necessary to elaborate on any of the above, please attach an additional page.
I/WE THE PARENT(S)/GUARDIAN(S) OF ________________________________________________________
HEREBY CONSENT TO OUR CHILD ATTENDING: _______________________________________________
_______________________________________________ FROM: ___________________TO: _______________
SHOULD IT BECOME NECESSARY FOR OUR CHILD 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 CHILD. WE UNDERSTAND THAT ANY COST WILL BE OUR RESPONSIBILITY. WE
ALSO UNDERSTAND THAT IN THE EVENT OF ILLNESS OR ACCIDENT, WE WILL BE NOTIFIED AS
SOON AS POSSIBLE.
Signature of Parent(s)Guardian(s): ___________________________
Date: ____________________________
____________________________________
Provision of the information and consent request on this form is voluntary; however, it may be required for the
health and safety of your son/daughter. The information provided will be held in confidence.
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,c.129 as amended. This information will be used for the purpose of providing health
and safety services in the event of an emergency. Questions regarding this collection should be directed to the School Principal.
November 2012