FIELD TRIP CONSENT FORM

ANNEX I
FIELD TRIP CONSENT FORM
(to be used for a specific field trip)
FIELD TRIP DESCRIPTION:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
(Name of Teacher)
I have read the above information pertaining to your field trip to ________________________
____________________________________________________________________________
(Location)
and hereby give my permission for ______________________________________________
(Name of Pupil)
to attend from ____________________________ to ________________________________
(Date)
(Date)
I give my permission to ____________________________________ to seek medical attention
(Name of the teacher/person responsible)
for my child in case of emergency.
Residence Telephone Number _____________________________
Business Telephone Number ______________________________
______________________________
(Date)
Signature:____________________________________
(Parent/Guardian)
ANNEX II
GENERAL CONSENT FORM
(to be completed once at the start of each school year)*
Name of School:
Address:
__________________________________________________________
________________________________________________________________
________________________________________________________________
Attention:
________________________________________________________________
(Name of Teacher)
I have read the accompanying letter pertaining to short outings within walking distance of the
school that are to take place during the school year _________________ and do hereby give
my permission for:
_________________________________________
(Name of Pupil)
to take part in these outings for the school year _____________________
I give my permission to ___________________________________ to seek medical attention
(Name of the teacher/person responsible)
for my child in case of emergency.
Residence Telephone Number ______________________________
Business Telephone Number ______________________________
In the space below, please include any pertinent information concerning your son’s/ daughter’s
health, medication, allergies, etc.
____________________________________________________________________________
____________________________________________________________________________
________________________
(Date)
Signature: _____________________________________
(Parent/Guardian)
*The Governing Board may adopt this form or a similar form, adapted to the particular needs
of the school.
ANNEX III
FIELD TRIP INFORMATION FORM
For trips outside the Province of Quebec
(Intended as information for school board personnel and commissioners
and to be sent to the Director of Educational Services)
School: _____________________________________________________________________
Description of trip: ____________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Location of trip: ______________________________________________________________
Dates:
From ________________________
To__________________________
Cost per participant: ___________________________________________________________
Number of students: __________________ Number of chaperones: _____________________
Name(s) of field trip organizer(s): ________________________________________________
____________________________________________________________________________
NAMES OF ALL OTHER CHAPERONES
School Personnel
Other
____________________________________________________________________________
___________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Mode of travel: _______________________________________________________________
Special events or notes: _________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
_________________________________
Signature of school administrator
_________________________________________ _________________________________
Name of person completing this form (please print)
(Date)
ANNEX IV
FIELD TRIP REQUEST FORM
(To be given to the school principal or centre director)
Name of School:
Objective:
__________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Nature of trip/project: __________________________________________________________
Level of students: _____________________________________________________________
Number of potential students: _________________
Responsible person(s): _________________________________________________________
____________________________________________________________________________
Supervision duty to be covered (Day and Time): _____________________________________
____________________________________________________________________________
Number of volunteers: _______________________
Person making request: _________________________________________________________
Date: ____________________________________
Date of departure: __________________________ Date of return: ______________________
Mode of transportation: (Bus, etc.) ________________________________________________
Time: ____________________________________ Time: _____________________________
-----------------------------------------------------------------------------------------------------------------Entrance cost: ______________Bus cost: _______________Student cost: ________________
Approved: ________________________________
(Principal)
Date: _______________________
(Copy to be returned to person(s) responsible for organizing the trip.)
ANNEX V
EMERGENCY MEDICAL TREATMENT FORM
FIELD TRIPS
(To be completed at the beginning of each school year)
SCHOOL:
STUDENT’S NAME:
Student’s Québec Health Insurance No.:
Expiry Date:
Medical Alerts, Allergies, etc. (specify type):
If medication has been prescribed, please specify type:
If your child is using prescribed medication, he/she should carry this medication on his/her
person at all times, either hand-held or carried in a zippered pouch belt.
Name of Family Physician (if available):
EMERGENCY MEDICAL TREATMENT
The Undersigned hereby agrees that in the event that I or my spouse or parent/tutor/
guardian cannot be contacted within a reasonable period of time, the person in charge,
as indicated, be appointed to authorize the admission to hospital, if deemed necessary
by a medical doctor, and emergency medical treatment recommended by a medical doctor
to be given to the above named student while participating in this trip and related events.
Name of Parent, Tutor or Legal Guardian : ___________________________________________________
Home Address : __________________________________________________________________________
E-mail Address: ___________________________________________________________________________
Home Telephone No.: _______________________ Alternate Telephone No : ______________________
(neighbour or relative)
Business Telephone No : ____________________________
(father)
_______________________________
(mother)
Mother’s Maiden Name: ___________________________________________________________________
_________________________________________________
Signature
ANNEX Vl
______________________________
Date
ANNEX VI
List of Activities Considered High Risk
and Must not be Practised
4 April 2002
Trampoline, delta plane, parachuting, hand gliding, bungee jumping, go-kart racing, bicycle
racing, motorcycle racing, mountain bicycling, snowmobile riding, mountain climbing, rock
climbing, ice climbing, cave exploring, horseback riding, scuba and deep sea diving, river
snorkelling, rafting, white water canoeing, sail boarding, sailing, kayaking, dog sledding,
ballooning, downhill ski racing, tubing on snow, ATV riding, and paint ball games.
ANNEX VII
ACCIDENT REPORT
Name of School/Centre______________________________________________ Policy No._________________
Certificate No._____________
Contact Person_____________________________________________________ Tel.______________________
Fax______________________
CLAIMANT
1.
Family Name_______________________________ Name_____________________________ Age_______
2.
Address______________________________________________________ Tel._______________________
3.
Date___________________________________________ Time: A.M._____________ P.M._____________
4.
Location of Accident______________________________________________________________________
5.
a) Briefly describe the accident____________________________________________________________
____________________________________________________________________________________
b) Describe the injury____________________________________________________________________
____________________________________________________________________________________
6.
Name of person responsible on duty at the time of the accident (if applicable):
________________________________________________________________________________________
7.
Immediate measures:
First aid_________________________________________________________________________________
Method of transportation to health services___________________________________________________
Method of transportation home_____________________________________________________________
Method of transportation to hospital_________________________________________________________
8.
Witness:
1.
Name_____________________________________________________________________
Address__________________________________________ Tel._____________________
2.
Name_____________________________________________________________________
Address__________________________________________ Tel._____________________
Signature_________________________________________________ Date______________________________