d’Youville S. S.

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d’Youville S. S.
10815 Dixie Road, Brampton, Ontario L6R 2W5 Tel: 905-789-5560 Fax: 905-789-1143
February 23, 2012
Dear Outdoor Club Parents:
The d’Youville Outdoor Club is planning our second rock climbing event of the year. As
in other years, this event will take place at Joe Rockhead’s Climbing Gym in Toronto.
It is one of the best indoor climbing facilities in Ontario.
Student members will have the opportunity to take climbing lessons with the professional
and highly trained staff at Joe Rockhead’s. They will learn the basics of using a harness,
tying into ropes, belaying and climbing techniques. At all times, the staff at Joe
Rockhead’s stresses the importance of safety and fun. These lessons and climbing time
will cost each student $25.
The Outdoor Club plans to leave right after school on Friday March 2nd, and arrive at
the climbing gym by 3:30PM. We will climb until 6:30PM and then have dinner at a fastfood restaurant nearby. The school busette will return to the school with all students
by 8:30 PM. We ask that you please be at the school to pick up your son or daughter at
that time.
In this package you will find the permission form and a waiver form from Joe
Rockhead’s. Please complete these in full, and return the forms and money to Mr.
Roach (in the science office) by February 29th. This is the day of our next Outdoor Club
meeting. Please note that we are limited to 24 participants (this is the number of
students that can be transported in the school busette)
Carpe Diem!
Sincerely,
The Outdoor Adventure Club Supervisors
T. Snihura
J. Balcita
B. Roach
J. Thomas
S. Jardine
J. Chlebowski
DUFFERIN-PEEL CATHOLIC DISTRICT SCHOOL BOARD
St. Marguerite d’Youville
Event #
School is arranging the event/activity described below.
THIS FORM MUST BE SIGNED FOR STUDENTS WHO WISH TO PARTICIPATE.
To Parents and Guardians: The purposes of this form are: 1) to inform you of the nature of the program; and 2) to seek
your support and permission for your child to participate.
Teacher:
Date(s):
B. Roach, T. Snihura
March 2, 2012
Destination(s):
9-12
Grade:
School Phone #:
(Times) Departure:
2:30 PM
Return:
8:30 PM
Joe Rockhead's Climbing Gym, 29 Fraser Ave, Toronto ON
Method of Travel:
school busette
Educational Purpose(s):
Cost for Student:
Activities to be undertaken:
Requirements: Lunch:
$25.00
Extracurricular event as part of the Outdoor Club.
Physical Description of the area to be visited (e.g. lake, park, river, etc.):
Clothing:
(905) 789-5560
Indoor rock climbing gym.
Indoor rock climbing and dinner afterwards at a nearby restaurant.
No
Money:
Yes
Notebook:
No
Other:
Athletic clothing: running shoes, long pants or long shorts, t-shirt.
The visit will be supervised by:
T. Snihura, B. Roach
NOTE TO PARENTS: Prior to the visit, 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.
Date:
Feb. 23, 2012
Teacher in charge:
T. Snihura
Principal:
Please print
K. Greco
Please print
Please sign this form, and return it to the school no later than:
February 29, 2012
Date
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 is being held.
Participant must assume these risks.
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.
ACKNOWLEDGEMENT: We have read and understand these warnings.
Signature of Student
Date
Signature of parent/guardian or
Student 18 years or older
Date
PERMISSION: I give my permission for my child (Name):
to participate in the
rock climbing event
to be held at
on
Signature of Parent/Guardian or Student 18 years or older
Joe Rockhead's climbing gym
March 2, 2012
Date
School/Youth Program Liability Waiver
Waiver
I, The undersigned, acknowledge and agree that observing or participating in the activities sponsored and or offered by Joe
Rockhead’s Climbing Gym Ltd. has INHERENT RISKS, including but not being limited to lead climbing, lead belaying, top roping,
bouldering. Those risks include but are not limited to:
1. Injuries resulting from the fall of other persons who may come in contact with me or from any falls in which I come into contact
with other persons;
2. Injuries resulting from the result of myself falling, including but not being limited to, falling into other persons, falling and coming
in contact with any walls, building structures, ropes. The result of falling to the ground, accidental or bad belaying. Climbers are
responsible for choosing a competent belayer.
3. Injures that occur from the NEGLIGENCE or lack of adequate training in equipment or health.
4. Injuries or death resulting from the negligent misuse of the facilities, climbing walls or equipment of Joe Rockhead’s Climbing
Gym Ltd., during leading, top roping, bouldering.
5. Injuries or death resulting from failure of equipment, or poor judgment of any equipment, including but not being limited to ropes,
carabiners, quick draws, bolt hangers, belay devices, harnesses.
I am aware of these and numerous other inherent risks in observing and or participating in the activities offered and or sponsored
by Joe Rockhead’s Climbing Gym Ltd. I ASSUME COMPLETE RESPONSIBILITY for those risks and for injuries that may occur
as a result of those risks EVEN IF injuries occur in a MANNER that is NOT FORESEEABLE at the time I sign this agreement. I
realize that by voluntarily assuming the risks involved, I will be SOLELY RESPONSIBLE for any loss or damage I sustain, including PERSONAL INJURIES to me, damage to my property, or damage arising out of my death.
WARNING: This agreement is legally binding. By signing it, you give up your right to recover compensation through the courts or
otherwise, for any personal injury, damage to your property, or for your death, being caused by negligence, accident, or otherwise.
I am aware of the potential risk and danger involved in climbing, lead climbing, lead belaying, top roping, all other belaying, bouldering; and waive and release Joe Rockhead’s Climbing Gym Ltd., all staff, volunteers, landlords, and owners of any liability relating
to the use of Joe Rockhead’s Climbing Gym Ltd.
I HAVE READ AND FULLY UNDERSTAND AND AGREE TO THE ABOVE RULES AND CONDITIONS.
Participant’s Name
Participant’s Age
Participant’s Signature
Telephone Number
For Participants under 18 years of age:
Parent/Legal Guardian’s Name
Parent/Legal Guardian’s Signature
Daytime Phone Number
Joe Rockheads
29 Fraser Avenue
Toronto M6K 1Y7
Date
Fax. (416) 538.2615
Tel. (416) 538.7670
email:
[email protected]
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