d’Youville S. S.
10815 Dixie Road, Brampton, Ontario L6R 2W5 Tel: 905-789-5560 Fax: 905-789-1143
Dear Parents:
We are excited this year to have the opportunity to supervise the activities of d’Youville’s very
own Outdoor Adventure Club. Club members will have the opportunity to participate in a
variety of outdoor (and some indoor) adventure activities. This year the club plans to focus on a
mixture of day trips for hiking, orienteering, mountain biking, cross-country skiing, snowshoeing,
indoor and outdoor rock-climbing. Only if there is enough interest will there be an effort to
organize multi-day trips such as a camping, a winter activities weekend or canoeing trip.
In addition to the outdoor activities, the club will be running regular in-school meetings
(approximately once every two weeks) where members will take part in organizational aspects
of the club, as well as various skills development (which may include skills such as using a
compass, tying knots, first aid kits, menu and trip planning) and some short events taking place
at nearby locations such as Heart Lake Conservation Area.
The cost for joining the Outdoor Club this year is $20. This fee helps to defray some of the
costs such as park entrance fees, transportation costs, and supply teachers for school-day trips.
Student members are expected to demonstrate their commitment by regularly attending the
Outdoor Club meetings. Depending on availability of a bus and/or bus driver, we look forward to
the participation of parents for transportation on some of the smaller one-day trips. Many of the
events will be organized for after school or on weekends so as not to impact the academic life of
the members.
In this package you will find several forms:
 general membership form
 medical consent form (2 pages)
 transportation consent form
 image release form
 activity payment form (no cheques are accepted)
We ask that you please fill these in completely and they will be kept on file for every trip the club
runs. As new events are planned, there will be additional permission and waiver forms that will
be posted on the school web site (www.tinyurl.com/outdoorclub). Events that do not have a
minimum number of participants will unfortunately have to be cancelled. Any forms that are
submitted incomplete can not be accepted.
The teacher supervisors in the Outdoor Club this year have a wealth of experience and a
diverse range of backgrounds applicable to many different activities and aspects of outdoor
adventure. We look forward to your support and encouragement of your son or daughter’s
participation in the d’Youville Outdoor Adventure Club. If you have any questions or concerns,
please do not hesitate to call one of the teacher supervisors listed below at (905) 789-5560.
Carpe Diem!
Sincerely,
The Outdoor Adventure Club Supervisors
T. Snihura
J. Balcita
B. Roach
J. Thomas
S. Jardine
J. Chittenden
J. Manasterski
d’Youville Outdoor Adventure Club
General Membership Form 2011-2012
First Name:
Home Address:
Last Name:
Number
Street
First Name
Last Name
First Name
Last Name
Postal Code
st
1 Parent/Guardian
Primary Contact Phone: (
nd
2 Parent/Guardian
Emergency Contact
Student Date of Birth:
Secondary Contact Phone: (
)
Emergency Contact Phone: (
)
Age:
(mm/dd/yyyy)
)
Grade Level:
Student Timetable (inform Outdoor Club leaders if your schedule changes)
Semester ONE
Period
1
2
3
4
5
Course
Period
1
2
3
4
5
Course
Teacher
Room
Teacher
Room
Semester TWO
Outdoor Activity Experience – please check the activities you have participated in the past:
d’Youville Outdoor Club events
Certifications
 Day hikes
 Backpacking in Algonquin
 Camp Medeba
 Canoe trip to Algonquin or Killarney
 Indoor Rock Climbing
 Outdoor Rock Climbing
 Cross-country skiing
 First Aid
 Advanced First Aid
 Life guarding (NLS)
 ORCA
 Other:
Activities outside of school (include relevant details)
 Camping in tents
 Canoeing
 Hiking
 Mountain biking
 Cross-country skiing
 Rock climbing (indoor)
 Rock climbing (outdoor)
 Other: (please list)
GF 080
Page 1 of 2
THE DUFFERIN-PEEL CATHOLIC DISTRICT SCHOOL BOARD
MEDICAL CONSENT FORM
SCHOOL NAME:
St. Marguerite d’Youville Secondary School
We, the parents/guardians of
Hereby consent to our child attending
from
September 2011
d’Youville Outdoor Adventure Club events
to
June 2012
Should it be necessary for our child to have medical care, I hereby give the teacher permission to use his/her
best judgment 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/Guardian:
Phone (day):
Phone (night):
Address:
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.
REV.04/92
(Please complete both sides)
GF 080 Page 2 of 2
THE DUFFERIN-PEEL CATHOLIC DISTRICT SECONDARY SCHOOL BOARD
HEALTH AND SAFETY INFORMATION FORM
SCHOOL NAME:
St. Marguerite d’Youville Secondary School
Name of Child:
Age:
Address:
Date of Birth:
Family Doctor:
Telephone:
Sex:
Student’s Health Card Number:
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 condition which must be taken into consideration in his/her participation in
the full program:
Allergy:
Diabetes:
Epilepsy:
Feet or Legs:
Heart:
Rash:
Recent illness or operation:
Rheumatic Fever:
Any other disability:
(2) Has he/she any drug allergy or sensitivity? If so, give details:
_________________________________________________________________________________
(3) Has he/she any serum sensitivity? If so, give details:
_________________________________________________________________________________
(4) Give date of last tetanus shot and reason for it:
_________________________________________________________________________________
(5) If your child has any special night-time habits, any special fears or nervous peculiarities, (e.g.: bedwetting, nightmares) knowledge of which will allow the teacher to make his/her visit more relaxed,
please state:
_________________________________________________________________________________
If more information is necessary, please attach an additional sheet of paper.
Signature of Parent/Guardian
Date (mm/dd/yyyy)
(Please complete reverse side)
MUNICIPAL FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY ACT, 1989: Personal information on this form is collected under the legal
authority of the Education Act, R.S.O. 1980. c.129 and Health Cards and Numbers Control Act. 1991. This information will be used for the purposes of: planning
and administering out-of-school programs for students, providing health and safety services in the event of an emergency including provincially funded health
resources and statistical analysis. Questions regarding this collection of personal information should be directed to the School Principal, c/o The Dufferin-Peel
CDS Board, 40 Matheson Blvd. West, Mississauga. Ontario. L5R 1C5 Tel: (905) 890-1221 or 1 800 387-9501
GF 117 S
Dufferin-Peel Catholic District 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:
d’Youville Outdoor Club events
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 the school van, 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 (non-student) volunteer, to and from the activities described above.
Parent/Guardian Signature: ________________________________________________________________
3.
My child may ride in the school van 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 the Board to transport other students, and that my child is
covered under my automobile insurance policy.
Parent/Guardian Signature: ____________________________________ 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. 1980, c.129. 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.
(Revised April 2007)
Dufferin-Peel Catholic District School Board
40 Matheson Boulevard West, Mississauga, ON, L5R 1C5, 905-890-1221
IMAGE RELEASE FORM
For d’Youville Outdoor Club Events 2011-2012
Dear Parents and Guardians:
Your son or daughter has joined the St. Marguerite d’Youville Outdoor Adventure Club this year.
During our events this year, photographs and video will be taken. On occasion, these photos may
be used for publicity purposes within or outside the school. As an example, photos may also be
placed on the Outdoor Club web page on the school’s web site. Please indicate your consent for
your son or daughter’s photo to be published by completing the bottom portion of this form.
------------------------------------------------------------------------------------------------------------
Dufferin-Peel Catholic District School Board
40 Matheson Boulevard West, Mississauga, ON, L5R 1C5, 905-890-1221
IMAGE RELEASE FORM
I hereby consent to the activity/event, as described above. I understand that photographs, written
work, video and audio recordings, may be used, edited and released to newspapers, radio,
television and internet providers.
I hereby release the Dufferin-Peel Catholic District School Board and its employees and assignees
from all claims resulting from the use, editing and release of any photographs, written work, video
and audio recordings with respect to this event/activity. This consent shall be continuing with no
limitations or reservations, except those stated above.
Date: __________________
Student Name: ___________________________________
Parent/Guardian Signature: _________________________
(If student is 18 years of age or older)
I am at least 18 years of age, and I consent to this authorization and release.
Student Signature: _______________________________