Mediated Learning Academy
550 Thompson Avenue
Coquitlam, BC V3J 3Z8
Telephone: 604-937-3641
Fax: 604-931-5155
FIELD TRIP AUTHORIZATION FORM
For Grades 11 & 12 Div- 9 & 10
I, ____________________________ , PARENT/GUARDIAN, HEREBY GIVE
PERMISSION TO MY CHILD, ______________________ , TO ATTEND
THE FIELD TRIP ON: _Friday Dec 18, 2015_ To Photography Winter
Wonderland
Address of Location: 4720 Kingsway Burnaby, BC V5H 4N2
Leave MLA: 8:45
Leave Site: 11:15
TRANSPORTATION FOR THE TRIP WILL BE: Staff Drivers
THE COST OF THE FIELD TRIP WILL BE: $2.00 (gas money)
REQUIREMENTS:
Camera for Photos
If your child requires medication, please make sure they have enough for
the trip and that authorization is on file at the school.
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PLEASE SIGN/RETURN THIS PORTION OF THE FORM TO THE OFFICE BY:
Thursday December 10, 2015
“I confirm that M.L.E. Training and Research Society, known as Mediated Learning Academy, propose to provide [child’s name]
____________________
with the opportunity to attend a field trip to [describe
field trip] Photography Winter Wonderland (the “Field Trip”). I acknowledge that my son/daughter is not obligated to attend this
field trip, and that by signing below I am providing my consent to my child attending the Field Trip, and I agree to assume any
inherent risk which may exist as a consequence of my child participating in the Field Trip. I am executing this release, waiver and
indemnity freely and voluntarily without any compulsion on the part of the Mediated Learning Academy. I further acknowledge
having read the entire text herein prior to signing this release, waiver and indemnity.
In consideration of my son/daughter participating in the Field Trip, I hereby agree to indemnify and save harmless M.L.E. Training
and Research Society, known as Mediated Learning Academy, and its directors, officers, employees, representatives and agents
(“MLE”) from and against all actions, damages, claims and demands which may hereinafter be brought against MLE, by or on
behalf of myself or our child in respect of or arising out of any matters in relation to the Field Trip, including matters in relation to
(a) any travel to or from the location of the Field Trip; (b) any matters arising while in attendance at the Field Trip (c) any
negligence on the part of MLE; or (d) the breach of any statutory duty of care on the part of MLE. I further agree, on behalf of my
child, to release and forever discharge MLE from any and all claims, demands or actions for any loss or damage which I or my
child my suffer or incur on account of personal injury, death, or property loss or damage arising as a consequence of my child’s
participation in or attendance at the Field Trip.”
PARENT SIGNATURE __________________________________
DATE