Permission Form For Field Trip printable pdf download

ES – 5016 STUDENT FIELD TRIPS & EXCURSIONS

APPENDIX E

INFORMED CONSENT / PERMISSION FORM FOR FIELD TRIPS (Students under 18 years)

Bracebridge Public School is arranging the following activities as a part of “Walk & Roll to School Day” to take

place on Wednesday, June 22nd between 8:00 am and 8:45 am in the community and 9:00 am and 10:30 am at

school.

Please indicate your child’s participation by checking the appropriate boxes below:

ALL STUDENTS – this portion of the day is supervised by ‘Walk & Roll to School’ Volunteers

 my child regularly walks to school and will be riding their bicycle / skateboard / scooter on June 22

 my child regularly takes a bus and will be riding bicycle / skateboard / scooter from a drop off location

 Salvation Army

 Knox Presbyterian Church

 Annie Williams Park

 my child will be taking their bus to school and I will be bringing their bicycle / skateboard / scooter to school

 my child will be taking their bus to school

KINDERGARTEN TO GRADE 3 - this portion of the day is supervised by BPS staff & volunteers

 my child will participate in the Walk & Roll Activities at school on their own bicycle / skateboard / scooter

 my child will participate in the Walk & Roll Activities at school on a school tricycle

GRADE 4 TO 8 - this portion of the day is supervised by BPS staff & volunteers

 my child will participate in the Walk & Roll Activities in the community with their bicycle / skateboard / scooter

 my child will participate in the Community Walk

ALL STUDENTS - this portion of the day is unsupervised

 my child will be riding their bicycle / skateboard / scooter home on June 22

 my child will leave their bicycle / skateboard / scooter at school and I will pick it up on ___________________

 my child will be taking their bus home

THIS TRIP IS SANCTIONED AND APPROVED BY THE APPROPRIATE TRILLIUM LAKELANDS DSB OFFICIALS.

________________________________________________________

Signature of Principal

THIS FORM MUST BE READ AND SIGNED BY EVERY STUDENT WHO WISHES TO PARTICIPATE AND

BY THE PARENT / GUARDIAN OF THE PARTICIPATING STUDENT.

ELEMENTS OF RISK:

Educational activity programs, such as the activity described above involve elements of risk. Injuries may occur while

participating in these activities. The chance of a student being injured can be reduced if your student behaves respectfully

and appropriately and carefully follows instructions at all times while engaged in the activity.

If you choose to participate in the activity described above on the date listed, you must understand a condition of your

student’s participation is that you bear the responsibility for any injury that might occur.

Trillium Lakelands District School Board does not provide accident insurance coverage for student injuries that occur on

school premises or during school activities. The Board makes available an Accident and Life insurance program through

Reliable Life Insurance Company. Participation is voluntary and costs are to be paid by the parent or guardian. You may

apply directly at or by calling toll free 1-800-463-5437.

ACKNOWLEDGEMENT AND PERMISSION:

I HAVE READ THE ABOVE. I UNDERSTAND THAT IN PERMITTING MY STUDENT TO PARTICIPATE IN

THE ACTIVITY DESCRIBED ABOVE, I AM ASSUMING THE RISKS ASSOCIATED WITH MY STUDENT’S

PARTICIPATION IN THE ACTIVITY. I HAVE REVIEWED WITH MY STUDENT THE NEED TO ACT

RESPECTFULLY AND APPROPRIATELY AND TO CAREFULLY FOLLOW THE INSTRUCTIONS OF

SUPERVISORS OF THE ACTIVITY.

I acknowledge that I have read and accepted the terms of the foregoing paragraph and I give my student permission to

participate in the activity described above on the date listed.

Specify any health considerations and/or special diet restrictions:

__________________________________

__________

______________________________

Name of Student (Print Clearly)

Grade

Student Number

__________________________________

______________________________

Signature of Student

Date

__________________________________

Signature of Parent / Guardian

Date

Permission Form For Field Trip

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