GF 115
PARENT/GUARDIAN PERMISSION FORM
FOR OUT-OF-SCHOOL / EXTRA CURRICULAR ACTIVITIES
Lester B. Pearson Catholic Elementary School
_______________________________________________________________________________
School
is arranging the out-of-school/extracurricular activity described below.
THIS FORM MUST BE READ AND SIGNED BY EVERY STUDENT WHO WISHES TO PARTICIPATE AND/OR
BY A PARENT/GUARDIAN OF A PARTICIPATING STUDENT
The purpose of this form is to: 1) inform you of the nature of the out-of-school/extracurricular
activity and 2) to seek your support and permission for your child to participate.
Monday, January 27th, 2014
Please sign this form, and return it to the school no later than: ________________________________
Teacher: P. Mantenuto
Grade:
905-793-4861
School Telephone: _______________________
Event/Activities to be Undertaken:
Exhibition Hockey Game vs. St. Anthony Catholic School
_____________________________________________________________________________________
_____________________________________________________________________________________
Monday, January 27, 2014 Departure Time: _____________
7:15am
8:15am
Date(s): _________________________
Return: ____________
students should arrive at 7:00am to dress and be transported by parent
Educational Purpose(s): _________________________________________________________________
Terry Miller Recreational Centre
Destination(s): ________________________________________________________________________
Hockey Game
Physical description of the area to be visited (e.g. lake, park, river, etc.) __________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Transport by Parent/Guardian
Method of Travel: __________________________________
Cost for Student: ________________
Requirements: Lunch:
Money:
Notebook:
Other: ______________________
Hockey Equipment
Clothing: _____________________________________________________________________________
P. Mantenuto
The event/activity will be supervised by: ___________________________________________________
NOTE TO PARENT(S)/GUARDIAN(S): Prior to the out-of-school/extracurricular activity, there will be
classroom time devoted to establishing safety procedures. If your child has, or has had any previous or
current health problems which might affect his/her comfort or safety, would you please give full
particulars in writing, and telephone the teacher to discuss it.
The Acknowledgement and Permission to Participate Section on the back of this form must be
completed in full.
(Revised February 2013)
ELEMENTS OF RISK: Educational activity programs, such as sporting events or activities, field trips,
excursions 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: 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.
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 or Adult Student)
_________
(Date)
PERMISSION: I give permission for my child: ______________________________ to participate in:
_____________________________________, to be held at: _________________________________
(Name of out-of-school/extracurricular activity)
(Location)
on the following date(s): _______________________________________________________________
______________________________________
(Signature of Parent/Guardian)
___________________________________
(Date)
(Revised February 2013)
GF 116
AUTHORIZATION TO TRANSPORT STUDENTS – VOLUNTEER DRIVERS
PART A
This will authorize: ______________________________________________________________________
(Name of teacher or other adult/non student volunteer driver
1.
2.
3.
To transport students participating in the events listed on the attached school schedule:
OR
To transport students participating in the following school activity:
__________________________________________________________________________________________________
Vehicle Information: MAKE: _____________________ YEAR: ________ LICENCE #: ____________
Lester B. Pearson Catholic Elementary School
School Name: ____________________________
Date: ___________________________
Principal's Signature: ____________________________________________________________
Note: All * "Trip Drivers" including Volunteer Drivers are advised that in order to bring into effect the
Board's Excess Liability Insurance, they must:
a)
Use a licensed automobile which carries valid automobile Third Party Liability insurance as required
under Ontario legislation;
b) Provide the Board with prompt written notice, with particulars, of any accident arising out of the use
of a licensed automobile during a trip on the Board related business;
c) Be aware that the School Board's Excess Automobile Liability insurance comes into effect only after
the vehicle owner’s primary Third Party Liability insurance limit has been exhausted (to a maximum of
$20,000,000.00, in excess of personal coverage);
d) Be aware that any damage to the volunteer’s vehicle, the cost of any insurance deductible or
premium adjustment as the result of an accident while the vehicle is being used on Board-related
business is NOT covered by the School Board’s Excess Automobile Liability insurance;
e) Be aware that if the vehicle is equipped with passenger-side airbags, children under 12 years should
not be permitted to ride in the front seat (see vehicle manufacturer’s recommendations).
* Note: A "Trip Driver" is defined as any person authorized by the Board who has agreed to be a driver for
a certain trip while they are driving their own or another licensed automobile. This includes, but
is not limited to: Trustees, employees, teachers, parents/guardians, volunteers and officials of
the Board.
DECLARATION TO BE SIGNED BY DRIVER
I ______________________________________________, declare that:
a) I hold an unrestricted driver’s license and am authorized to drive in Ontario, and my vehicle is insured by a valid automobile
liability insurance policy as required by Ontario law.
b) the vehicle described above is mechanically fit and that there are seat belts in working condition for all passengers.
c) I have read and understand the Summary of Insurance contained in Part B, on the reverse side of this form.
Date:
________________________
Signature: ________________________________________________
SEE REVERSE SIDE OF THIS FORM FOR PART B, SUMMARY OF INSURANCE, AND, IF APPLICABLE, DECLARATION TO BE SIGNED BY
OWNER (IF DRIVER DOES NOT OWN VEHICLE)
(November 2012)
DECLARATION TO BE
SIGNED BY OWNER (IF DRIVER DOES NOT OWN VEHICLE)
I___________________________________________________, declare that:
a) I have authorized ______________________________ to drive my vehicle to transport students participating in the school event(s)
listed on this form.
b) I declare that he/she holds an unrestricted driver’s license, is authorized to drive and is insured as an operator under the
vehicle’s liability insurance.
c) I declare the vehicle described above is mechanically fit and that there are seat belts in working condition for all passengers.
d) I have read and understand the Summary of Insurance contained in Part B.
Date:
Signature: _______________________________________________
PART B
SUMMARY OF INSURANCE
(1) Volunteer Supervisors on School Premises
The school board's Liability insurance policy protects both staff and volunteers who are working within
the scope of their duties for the board. This coverage responds to law suits that are brought against staff
or volunteers who are supervising school events and provides protection up to $20 million for each
occurrence.
(2) Volunteer Drivers for School Activities
Ontario legislation makes automobile insurance compulsory in the Province of Ontario. The same
legislation makes the owner's insurance primary coverage in the event of an accident - in other words, the
insurance carried on the vehicle responds first. If a vehicle which is not owned by the school board is
being operated by a volunteer or any other board employee for approved school activities, the board's
Non-owned Automobile Insurance endorsement will respond to Third Party Liability claims in excess of
the owner's insurance limit up to a total combined limit as stated in the Non-owned Auto policy. There is
no coverage provided by the school board's insurance for damage to volunteer's or employee's vehicles
while they are being operated for board activities. According to Provincial legislation, passengers who are
injured would recover Accident Benefits coverage from their own or a parent's automobile policy. In the
absence of a personal or family automobile policy, the passenger would then be eligible to recover
benefits from the insurance policy covering the vehicle in which they were riding.
(3) Personal Automobile Insurance Coverage
For the personal protection of volunteer drivers, it is recommended that drivers carry a minimum of $1
million of Third Party Automobile Liability insurance. Volunteers and board employees who use their
personal vehicles for transporting students to school activities should advise their insurance carrier.
Distribution:
Driver_____
Principal _____
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. This information will be used for the purpose of: planning and
administering out-of-school programs for students, insurance and statistical analysis. Questions regarding this collection of personal
information should be directed to the School Principal.
(November 2012)
GF 117 E
PARENTAL/GUARDIAN PERMISSION TO TRANSPORT ELEMENTARY
STUDENTS IN A PRIVATE AND/OR COMMERCIAL VEHICLE
NOTE: Only Applies to School Approved Student Activities/Excursions
Date: _______________________________
Dear Parent/Guardian of: _______________________________________________________________
Hockey Game @ Terry Miller Recreation Centre
Description of Activity: _________________________________________________________________
_____________________________________________________________________________________
Due to the nature of these activities, some are unable to be offered at the school. It will, therefore, be
necessary for the students to travel to other facilities off school property. Transportation to these
facilities will be accomplished in one or more of the following ways: Some students will travel via a
Board-approved taxi, or some via a personal vehicle driven by a Board approved adult (such as a staff
member or a non-student volunteer).
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 my permission for my child to ride in a private car, driven by the teacher or
another Board approved (non-student) adult volunteer, to and from the activities described
above.
Parent/Guardian Signature: ____________________________________________________
2. 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 (applicable only to students in Grade 4
or higher).
Parent/Guardian Signature: ____________________________________________________
3. I will drive my own child to and from the activity described above.
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.
Parent/Guardian Signature: ____________________________ Date: ______________________
MUN ICIPAL FREEDOM OF IN FORMATION AN D PROTECTION OF PRIVACY ACT: Personal inform ation on this form is
collected und er the legal authority of the Ed ucation Act, R.S.O. 1980, c.129. This inform ation w ill be used for the purpose of:
planning and ad m inistering out-of-school program s for stud ents, insurance and statistical analysis. Questions regard ing this
collection of personal information should be d irected to the School Principal.
(Revised February 2013)
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:
Hockey @ Terry Miller Recreation Centre
_____________________________
(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)