Form 511C
Aug. 30, 2004
Page 1 of 5
October 6th, 2013
Dear Parent/Guardian,
The University of Waterloo’s Kinesiology Lab Days provides a structured field trip opportunity for Exercise Science and Biology
students to visit the University of Waterloo’s kinesiology lab facilities and engage in hands-on activities related to kinesiology – the
science of human anatomy, physiology and biomechanics. Students will participate in mini-laboratory sessions under the instruction of
graduate and senior undergraduate students and attend a brief presentation on Kinesiology at Waterloo. Each student attends 3
sessions. The labs have been designed to introduce a wide range of topics from examining how muscles work to determining your
fitness level or analyzing gait patterns – with maximum opportunity for participation. As well the Dietary Forensics lab will give
students an up-close and personal viewpoint of a working biochemical laboratory. Please see the back of this page for a full
description of the labs taking place during this field trip.
The total cost for each student is $30.00. This includes the cost Waterloo charges for the lab activities and the cost of a chartered
coach that will transport students to the University and back to Martingrove.
This trip is an optional component of the Exercise Science and Biology courses. Students going on this trip are responsible for
any missed worked and should speak to their teachers in advance of Thursday December 5th.
Itinerary for the Day:
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Students meet at Martingrove for 8am
8:15am sharp Coach Leaves for Waterloo
10:15 a.m.
Group Welcome Session (introduce Kinesiology and format for the day)
10:45 a.m.
Meet Instructor and Proceed to Session 1
11:45 a.m.
Break for Lunch (45 minutes)
12:30 p.m.
Meet in BMH Foyer and Proceed to Session 2
1:30 p.m.
Meet in BMH Foyer and Proceed to Session 3
2:30 p.m.
Depart
4:00 pm
Arrive at Martingrove
Mr. Youssef
Exercise Science Teacher
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Form 511C
Aug. 30, 2004
Page 2 of 5
You will attend 3 sessions on December 5th. After reading the descriptions below please indicate your top 3
choices plus one alternate by ranking the session numbers in the blanks here:
Name: ______________
Choice A: _____ , Choice B:______, Choice C: _____ , Alternate:______
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Form 511C
Aug. 30, 2004
Page 3 of 5
Parent/Guardian Permission for Excursion
The collection and retention of the information requested on this form is authorized and governed
by the Ontario Education Act and the Municipal Freedom of Information and Protection of Privacy Act.
School: Martingrove C.I.
Telephone: 416-394-7110
Teacher(s): Mr. Youssef
Student:
Nature of Activity: Kinesiology Lab Day
Destination: University of Waterloo Kinesiology Labs
Grade/Class: PSE4U1
Date of Excursion: Dec.5th, 2013
To Parents and Guardian:
The purpose of this form is to inform you about the excursion and to seek your support and permission for your child/ward to
participate. This information may be shared as necessary with adults supervising the excursion.
This is an important document. Please ensure that someone is able to translate and explain this document to you.
Purpose of the excursion: Students will be choosing from a variety of lab activities to be engaged in at the Kinesiology Labs of the
University of Waterloo
Itinerary
Program/itinerary: Students will be picked up by coach at MCI, go for the day to Waterloo and return by coach to MCI.
Departure: From MCI
Return: To MCI
Date: December 5th, 2013
Time: 8:00am at meet at Martingrove C.I.
th
Date: December 5 , 2013
Time: 4pm return to Martingrove C.I.
In exceptional circumstances, dates and times may change. Every effort will be made to communicate these changes to you ahead of time.
Method of Travel
Students will travel together on the chartered coach.
*Approval of the principal is required for all volunteer drivers. The school will make every effort to ensure that parent/guardian consent is obtained for each excursion
for students to travel in private vehicles.
Requirements for Participants
Food/snacks: Bring lunch or money for lunch Money: $30.00/student covers the cost of the lab activities and coach.
Clothing and equipment: Please ensure that your son or daughter dresses appropriately for the weather on that day.
Other: Please ensure that your son or daughter eats a nutritious breakfast before arriving at Martingrove.
Note:
Financial Arrangements
Total cost per student: $30.00/student
Excursion Staff
Teacher: Mr. A. Youssef
Payable to: cash or cheque (payable to Martingrove Collegiate).
School contact during the excursion: Mr. R. Nigro
Staff Supervisors:
Volunteer Supervisors (if known): _____________________________________________________________________________
Teacher
Signature
Date
Administrator
Signature
Date
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Form 511C
Aug. 30, 2004
Page 4 of 5
Please sign in either the YES or the NO box and return this form to the teacher by: Thursday Oct. 10th/13
YES
I/we give permission for my/our child/ward, _______________________________________,
to participate in the excursion to The University of Waterloo
Emergency Contact:
Emergency Phone Number:
I/we give permission for my/our child/ward to be transported in a private vehicle (adult driver) ____, private vehicle
(student driver)____ who has been authorized by the principal.
Parent Signature ___________________________________________________________
Is there any change in medical information or a medical reason why your child should not participate in the activity, or which may
lead him/her to require special attention during the activity?
Should it become necessary for my/our child/ward to have medical care, I/we hereby give the teacher permission to use her/his best
judgment in obtaining the best of such service for my/our child/ward. I/we understand that any cost will be my/our responsibility. I/we
also understand that in the event of illness or accident, I/we will be notified as soon as possible.
Name of Parent/Guardian________________________________________________________________________
(printed name of parent/guardian)
Today’s date:
Signature of Parent/Guardian
(or student, if 18 years old or older)
For students 18 years old or older, it is strongly recommended that the parent/guardian also sign this form.
I wish to volunteer on this trip:
Yes______
No______
Signature of Parent/Guardian________________________________________________________ Today’s date:_____________
(or student, if 18 years old or older)
NO
I/we do not give permission for my/our child, _____________________________________________________________, to
participate in the excursion to ___________________________________________________________________________ on
(date)
Name of Parent/Guardian ________________________________________________________________________.
(printed name of parent/guardian)
Today’s date:
Signature of Parent/Guardian
(or student, if 18 years old or older)
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Form 511C
Aug. 30, 2004
Page 5 of 5
Medical Information Form
The collection and retention of the information requested on this form is authorized and governed
by the Ontario Education Act and the Municipal Freedom of Information and Protection of Privacy Act.
The following information will be helpful to the teacher in making your child/ward comfortable and safe .
Student: ________________________________________________________________________Date of Birth: ________________________
Teacher: ___________________________________________________ Grade/Class: ________________
Parent/Guardian: _____________________________________________ Telephone: (H) ___________________ (B) ___________________
Ontario Health Number: _______________________ Family Doctor: ______________________________ Telephone: _________________
Medical Conditions
Please indicate any significant medical conditions, physical limitations, or any other concerns that might affect your child’s/ward’s full
participation in excursions/school activities.
 Asthma
 Fainting Spells
 History of head injuries
 Rheumatic Fever
 Chronic Nosebleed
 Feet or Leg problems
 Migraine
 Seizures
 Diabetes
 Hemophilia/Bleeding disorders
 Rash
 Sleepwalking
 Digestive upsets
 Heart problems
 Recent illness or operation
 Urinary infections
 Ear, Nose, Throat infections
 Hernia
 Other ________________________
 Dislocated shoulder; swollen, painful joints; ‘trick or lock’ knee or other joint disability
Give details of usual treatment for each of the above conditions indicated: ___________________________________________________
______________________________________________________________________________________________________________
Please explain if your child/ward has any medical condition that requires any modification of his/her program. ______________________
______________________________________________________________________________________________________________
Allergies/Asthma
Please list all known confirmed allergies to the following:
(a) Foods: _________________________________________________________________________________________________________
If foods are life-threatening, please explain the symptoms and the treatment: _________________________________________________
__________________________________________________________________________________________________________
(b) Medications: ____________________________________________________________________________________________________
(c) Other (e.g., bee or wasp stings, environmental allergies): __________________________________________________________________
Has your child/ward suffered any serious allergic or asthmatic reaction?
If so, please provide details, including the type and severity of reaction: _____________________________________________________
Is allergy considered: Mild____ Moderate____ Serious____ Life-Threatening____
Has a doctor prescribed an Epi-Pen for your child/ward? Yes____ No____
Has a doctor prescribed an inhaler for asthma? Yes____ No___ (Prescribed asthma inhalers must be carried by the student on the excursion.)
Has a doctor prescribed an inhaler for any other reason? Yes____ No____
Dietary Restrictions
Please list any foods your child/ward should not eat for medical, dietary, or religious reasons: _______________________________________
______________________________________________________________________________________________________________
Medication
Does your child/ward take prescribed medication on a regular basis? Please specify: _______________________________________________
What prescribed medication(s) should your child/ward have with him/her during the excursion? ______________________________________
General
(1) Does your child/ward wear or carry medical alert identification (e.g., bracelet)? Yes____ No____
If yes, please specify what is written on it: ____________________________________________________________________________
(2) Does your child/ward have any other relevant medical condition that will require modification of the program? Yes____ No____
If yes, please explain: ____________________________________________________________________________________________
(3) Does your child/ward have any special fears or conditions (e.g., anxiety, bed-wetting, nightmares), the knowledge of which will allow the teacher
to make the student’s excursion more relaxed? Yes____ No____ If yes, please explain:
Should it become necessary for my child/ward to have medical care, I hereby give the teacher permission to use her/his best judgment in obtaining
the best of such service for my child/ward. I also understand that in the event of such illness or accident, I will be notified as soon as possible.
Name of Parent/Guardian: _____________________________________________________________________(Please print)
Signature of Parent/Guardian: __________________________________________________________Date: ____________
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