INFORMED CONSENT/PERMISSION FORM FOR EDUCATION TRIPS
(Students Under 18 Years)
‘The Calgary Science School is arranging the Grade 8 Camp Sweet from Sept. 13th to Sept. 15th, 2010 (8.3
and 8.4 students) or Sept. 15th to Sept. 17", 2010 (8.1 and 8.2 students),
‘THIS FORM MUST BE READ AND SIGNED BY EVERY STUDENT WHO WISHES TO PARTICIPATE AND BY A
PARENT OR GUARDIAN OF A PARTICIPATING STUDENT.
ELEMENTS OF RISK.
Educational activity programs, such as Camp Sweet involve certain elements of risk. injuries may occur
‘while participating in these activities. The following list includes, but is not limited to, examples of the
types of injuries that may result from participating in Camp Sweet
1. Cuts, bruises, sprains, and fractures
2. Bus Accident
3. Insect Bites
4, Encounters with wildlife
5. Injures from wild flora and fauna
‘The risk of sustaining these types of injures result from the nature of the activity and can occur without
‘fault of either the student, or the school board, its’ employees/agents or the facility where the activity Is.
taking place. By choosing to take part in this activity, you are accepting the risk that your/your child may be
injured.
‘The chance of an injury occurring can be reduced by carefully following instructions at all times while
‘engaged in the activity
Hf you choose to participate in the Grade 8 Camp Sweet trip from Sept. 13th to Sept. 15th, 2010 (8.3 and
8.4 students) or Sept. 15th to Sept. 17", 2010 (8.1 and 8.2 students), you must understand that you bear
the responsibility for any injury that may occur.
‘The Calgary Science School does not provide accidental death, disability or dismemberment or medical
‘expense insurance on behalf ofthe students participating inthis activity.
ACKNOWLEDGEMENT:
WE HAVE READ THE ABOVE. WE UNDERSTAND THAT PARTICIPATING IN THE ACTIVITY DESCRIBED ABOVE,
WE ARE ASSUMING THE RISKS ASSOCIATED WITH DOING SO.
Signature of student te
Signature of Parent/Guardian Date
PERMISSION:
‘give permission to participate in the Grade 8 Camp Sweet trip,
(Name of Student)
‘to be held on Sept. 13th to Sept. 15th, 2010 (8.3 and 8.4 students) or Sept. 15th to Sept. 17th (8.1 and 8.2
students).
Signature of Parent/Guardian Date.IE THE REGISTRATION/ONLINE INFORMATION REGARDING YOUR CHILD’S HEALTH (INCLUDING.
‘ALLERGIES) IS INCOMPLETE AND/OR NOT CURRENT, IT IS IMPERATIVE THAT YOU UPDATE
THAT INFORMATION ONLINE or COMPLETE THIS PAG
This information will be kept confidential in your child's file.
STUDENT'S NAME:
ADDRESS:
BIRTHDATE HOME PHONE:
PARENT/GUARDIAN: WORK PHONE:
ALBERTA HEALTH CARE NUMBER:
1. Does your child receive medication? Yes No
Do you permit your child to self-medicate? Yes. No
IF VOU WISH TEACHERS TO ADMINISTER MEDICATION, YOU WILL
NEED TO FILL OUT A LIABILITY RELEASE FORM.
2. Pl ‘the following that your child has or has had:
Diabetes: ves No
Asthma: Yes No.
Rheumatic Fever: Yes No.
Allergies: Yes No ___ {if yes, please list):
3, Has your child been away from home before? Yes_No.
4, Has your child been on an overnight trip before? Yes___No
5. Will you permit the teachers to admi
Yes No
ister light remedies such as Tylenol and Diovol?
6. Food re
7. Please list any other concerns of which the staff should be aware:
Parent’s Signature DateCalgary Science School
Extended Outdoor Education Trips
Authorization to Administer Medication and Release of Liability
This form is to be completed by a parent or legal guardian in consultation with a physician, if necessary, in
order to request the storoge and / ar administration of ony prescription or norprescrption medication to
«student by Calgary Science Schoo! staf. The information gathered for this requests valid for the current
school year or for the specified date range only and must be reviewed upon expiry in order to continue
storing or administering medication. Any chonge in this information must be reported to the school os
‘soon as practicable.
Student Name: Homeroom:
ia) Vist)
Dates of medication storage/administration: From / / to / /
DMY omy
MEDICATION INFORMATION: (To be completed by the Physician, for severe allergies or medical
conditions requiring prescription medication. A Physician’s Endorsement is required for administering
prescription medicine ~ see back of form.)
Parents can provide information for conditions not requiring prescription medicine.
Medical condition requiring medication:
Description of medication (common name if possible) and dosage:
Name of Medication Dosage Frequency Time of Day
***1f this medication is an epi-pen, the school requires that the child carry one with them at all times.
‘Medication storage requirements: Refrigerated medications cannot be stored during field trips.
Note: All medications to be administered during field trips must be contained in an original, childproof
container bearing an original label indicating the student’s name, medication type, dosage, and exoiry
date, Upon submission of this form, medications must be given to the teacher in charge of the outdoor
‘trip for storage and administration as required. Please note any other specific storage instructions below.
Possible side effects or expected reactions to medication: (Preseriotion medications must be accompanied
bya detailed drug information sheet)
Action plan in the event of a medical emergency resulting from this medication:
‘Adgitional instructions or information:PHYSICIAN'S ENDORSEMENT.
The preceding information provided by the parent/legal guardian is correct. Lives G1 No
‘The assistance required of staff is within the competence of a person untrained in medical procedures,
Doves CNo
Physician's Name (please print) Physielan’s Phone number
‘Physician's Location and Address
Signature of Physician bate
ACKNOWLEDGEMENT AND RELEASE OF LIABILITY BY PARENT OR LEGAL GUARDIAN:
| do hereby acknowledge that:
1. The student and the student's parent or legal guardian is,
administration of medication.
2. Approval ofthis request is valid only for the school year or date range specified.
3. Any change to the student’s medical condition or medication requirements is to be brought
to the Principals attention as soon as practicable.
4, Action taken by staff will be limited to what is possible ina school setting or during school
activities by persons untrained in medical procedures.
arly responsible for the
{mn signing this request for schoo! staff to assist with the storage and / or administration of medication
during an outdoor education trp, I release the Calgary Science School, i's servants, employees and agents
from and against all claims, suits, demands, and actions whatsoever taken now or in the future which may
arise from the administration of the indicated medication to the student named herein. Furthermore, |
authorize the staff to take emergency action as deemed appropriate in the event of an adverse reaction
to the administration of this medication.
(Parent / Legal Guardian = Print) (Parent / Legal Guardian - Signature) (oote)
PRINCIPAW’S APPROVAL
Signature of Principal
Personal information is collected under the authority of Alberta's Freedom of Information and Protection
cof Privacy Act (FOIP} and the Schoo! Act. The information will be used to assist with the administration of
‘medication and/or respond to potential emergency situations involving the student named herein. It will
be treated in accordance with the privacy provisions of the FOIP Act. If you have any questions about the
collection and/or its intended use, please contact the school FOIP Coordinator, phone (403) 282-2880,
5915 Lewis Drive SW, Calgary, AB T3E 524,