OCDSB 122 - Consent for Student Participation on a Field Trip
Trip Details
School:
School Year:
Merivale High School
2024-2025
Class/Group/Subject Area:
PAF2O,3O(F),4O
Name of Lead Trip Supervisor:
School Phone Number:
Krista Camick
(613) 224-1807
Field Trip Activity:
Fitness 10k Summative Race
Address/Destination:
Merivale High School + surrounding community
Transportation Type(s):
None
Recurring Field Trips:
This trip will recur on specific dates.
This trip will recur throughout the school year.
Departure Date and Time:
Return Date and Time:
5/23/2025
5/23/2025
9:25 AM
10:50 AM
Educational Purpose of Trip:
(Explain how this is associated with the curriculum)
Demonstration of fitness training, achievement of goal setting and teamwork/spirit.
Involved Physical Activity
Risk(s) Associated with the Activity:
Please consult Appendix C - Risk-specific Q&As.
Students are aware of safety considerations for running in the community (proper clothing, etiquette, safety,
etc.), teachers are supervising, first aid kit on site.
Risk Category:
Category 1: Low risk severity/low risk frequency.
Please explain in detail how you will mitigate the risk involved:
Students are aware of safety considerations for running in the community (proper training, clothing, etiquette,
safety, etc.), teachers are supervising, first aid kit on site.
Requirements of Participants
Cost Per Student:
$ 0.00
Cancellation and Refund Policy:
N/A
Financial support and other accommodations based on the Ontario Human Rights Code are available for
students. Please reach out to the Lead Trip Supervisor at .
Lunch/Snacks:
N/A
Special Clothing or Equipment:
Athletic attire and running shoes
Other requirements:
Water bottle
Student Information & Consent
Consent for Student Participation *
I give permission for my child/ward to participate in this field trip.
I do not give permission for my child/ward to participate in this field trip.
Prior to providing consent, I would like to schedule a meeting with the Lead Trip Supervisor regarding:
Student Information
Student First Name: *
Student Last Name: *
Andrew
EL-Kurdi
Grade *
Student Date of Birth: *
11
4/26/2008
Medications:
If there’s no information to share, please leave this field blank.
Allergies:
If there’s no information to share, please leave this field blank.
Medical Conditions:
If there’s no information to share, please leave this field blank.
Recent Injuries:
If there’s no information to share, please leave this field blank.
Please check the appropriate response pertaining to your child and provide additional
details below.
*
Details
Previous history of concussions
Yes
No
Fainting episodes during exercise
Yes
No
Asthma
Yes
No
Trouble breathing during exercise
Yes
No
Epileptic
Yes
No
Wears glasses
Yes
No
Shatterproof glasses lenses
Yes
No
Wears contact lenses
Yes
No
Wears dental appliance
Yes
No
Hearing problem
Yes
No
Heart condition
Yes
No
Diabetic
Yes
No
Has had an illness lasting more than a
Yes
No
Medication
Yes
No
Allergies
Yes
No
week in the past year
Wears a medic alert bracelet or
Yes
No
Yes
No
Presently injured
Yes
No
Any other health problems that could
Yes
No
necklace
Injuries/illnesses requiring medical
attention in the past year
interfere with their participation in
athletic activities?
Medical Consent:
Should it become necessary for my child/ward to receive medical care, I hereby authorize the teacher to use his/her best
judgment in obtaining such care. I/we understand that any costs will be my/our responsibility. I also understand that in the
case of accident or illness I will be notified as soon as possible.
Elements of Risk:
Any out of school activities may involve certain elements of risk. Injuries may occur while participating in the activities
related to this field trip. The chance of injury can occur without any fault of the student, the school board, its
employees/agents or the facility where the activity is taking place. I/we understand that any costs will be my/our
responsibility as the OCDSB does not provide accident insurance coverage for student injuries that occur during school
activities.
Acknowledgement:
*
I have received, read, and understand all of the above.
Parent/Guardian Information
First Name: *
Last Name: *
ANya
lysykova
Phone Number: *
Email: *
(613) 863-3844
anya_kurdi@yahoo.com
Emergency Contact Information
First Name: *
Last Name: *
Anya
lysykova
Phone Number: *
(613) 863-3844
Alternate Contact Information
First Name:
Last Name:
Matt
kurdi
Phone Number:
(613) 882-2864
Parent/Guardian/Adult Student Signature *
Date
Anya
4/13/2025
Personal information on this form is collected under the authority of sections 58.5(1) and 265(d) of the Education Act, R.S.O. 1990, c.E2, as amended, and in accordance
with section 29(2) of the Municipal Freedom of Information and Protection of Privacy Act. It will be used for the purpose of managing student learning and well-being.
Questions about this collection should be directed to the school principal.