OCDSB 122 - Consent for Student Participation on a Field Trip
Trip Details
School:
School Year:
Merivale High School
2024-2025
Class/Group/Subject Area:
PAD3O- group 2
Name of Lead Trip Supervisor:
School Phone Number:
Meghan Foottit
(613) 224-1807
Additional Supervisors and Contact Info:
Name:
TBD
Field Trip Activity:
Canoe Practice/Jock River Landing
Address/Destination:
Transportation Type(s):
School Bus
Departure Date and Time:
Return Date and Time:
4/25/2025
4/25/2025
11:15 AM
2:20 PM
Educational Purpose of Trip:
(Explain how this is associated with the curriculum)
OPHEA guidelines requirement for canoe trip participation
Involved Physical Activity
Risk(s) Associated with the Activity:
Please consult Appendix C - Risk-specific Q&As.
Canoeing
Risk Category:
Category 2: Medium risk severity/low risk frequency.
Please explain in detail how you will mitigate the risk involved:
Lifejackets will be worn, skill progression, canoe in sheltered area
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:
Water bottle and snacks
Special Clothing or Equipment:
Warm clothing, water shoes
Other requirements:
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
Student Medical Information:
If there’s no information to share, please leave this field blank.
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: *
matt
kurdi
Phone Number: *
Email: *
(613) 882-2864
matt.kurdi@gmail.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
Matt
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.