Académique Documents
Professionnel Documents
Culture Documents
ConsentofParentorGuardianandAcknowledgement
ofRiskforAandBOffSiteActivity/ies
CorporateRiskManagement
UpdatedMay2016
Page1of5
https://portal.cbe.ab.ca/service/ose/SitePages/Home.aspx# 1/5
3/23/2017 Off-Site Activities Enhanced - Home
Page1of5
UpdatedMay2016
Page2of5
https://portal.cbe.ab.ca/service/ose/SitePages/Home.aspx# 2/5
3/23/2017 Off-Site Activities Enhanced - Home
Page2of5
Schedule A
IMPORTANT Medical Information
Health Information: (Teacher will have a photocopy of this information during the OffSite Activity/ies to address health and medical
needs including emergencies and may share this information with others as deemed necessary.) Can be typed or handwritten MUST BE
COMPLETED BY A PARENT, GUARDIAN OR INDEPENDENT STUDENT
Activity:NationalMusicCentreFieldTripWordstoSong&Kimball Date(s):
Performance
StudentName:
DateofBirth(yy/mm/dd):
DrugAllergies? NoYesSpecifics/Severity:
FoodAllergies? NoYesSpecifics/Severity:
InsectAllergies? NoYesSpecifics/Severity:
OtherAllergies? NoYesSpecifics/Severity:
Pleasefilloutthemedicationnamesanddetailsforadministeringthem:(ifmorespaceisrequiredpleaseattachadditionalinformation)
Arethereanyknownsideeffectstoabovemedication(s)?Ifyes,pleasedescribe:
Doesthestudenthaveanypsychologicaloremotionalproblems?Ifyes,pleasedescribe:
Arethereanyrecentinjuriestobeconcernedabout?Ifyes,pleasedescribe:
MedicalTreatmentRestrictions(ifany)e.g.bloodtransfusions:
DietaryRestrictions(ifany):
AdditionalInstructions/Information:
Emergency Contact 1: Emergency Contact 2:
Name: Name:
Home: Home:
Mobile: Mobile:
Work: Work:
UpdatedMay2016
Page3of5
https://portal.cbe.ab.ca/service/ose/SitePages/Home.aspx# 3/5
3/23/2017 Off-Site Activities Enhanced - Home
Page3of5
IncompliancewithTheCalgaryBoardofEducation(CBE)AdministrationRegulation6002,parents/legalguardians/IndependentStudentsare
responsibleforprovidingmedicalsupportsandmedicationprescribedforthestudentbyaphysicianormedicalprofessionaltoensurethestudent
hasthesupportsandmedicationrequiredwhileatschoolorduringoffsiteactivities.TheCBE,itsteachersandstaffwillnotadministerthe
medicationorsupportsbutduringschoolactivities,shallstorethemedicationandsupportsandsupervisethestudentinselfmedicating.The
parent/legalguardian/IndependentStudentshallnotifytheTeacherofthenatureofthemedicationandsupports,thetimingofselfmedicationand
anyproceduresthatapplytosame.
If the student is registered in a CBE High School,therequirementofteacher/staffsupervisionofselfmedicationbythestudentandofstoring
medicationmaybewaivedbytheparent/legalguardian/IndependentStudentbymarkingintheboxbelowwithanX:
IdonotwishtheCBE,itsteachers/stafftostorethestudentsmedicationorsupervisetheselfmedicationbythestudent.
Pleasenotethat:
1. theprovisionscontainedinthisformaresubjecttotheCBE'sAdministrativeRegulation6002,asamendedfromtimetotime(availableforview
ontheCBEwebsite)andapplicablelawsand
2. theprovisionscontainedinthisformfurtheraresubjecttotheapplicableschoolsEmergencyResponseProtocolandanyparticularStudent
HealthPlancompletedbytheCBEwiththeparent/legalguardian/IndependentStudent.
Notwithstandinganyoftheforegoing,Iagreethatthemedications(prescription/nonprescription)listedonthefirstpageofthisformarethe
studentsresponsibilityandthestudentisresponsibleforhowthemedicationisstoredandwhenitistaken.I,theparent,legalguardianor
IndependentStudent,acceptresponsibilityinallcasesforanymedicationthatislost,stolenordamaged.IconfirmthattheTeacherhasbeen
informedaboutthenatureofthemedication(s),knownsideeffectsandconsequencesofmisseddosesorextradosesandanyotherpertinent
medicalinformationbyme.
To the best of my knowledge, the medical information contained in this form is accurate and up to date and I shall inform the Teacher
immediately of any changes to such information. I understand the risks involved in the taking of such medications by the student prior to
or during the offsite activity or trip in which the student shall be a participant. I further agree to the following:
a) in the event of a medical emergency involving the student, the Teacher or his/her designates and any applicable CBE personnel or the
Service Provider service provider may seek immediate professional medical assistance and CBE may disclose the information
concerning the medications and all other relevant personal information concerning the student to professional medical advisors or
paramedics as reasonably required and
b) if the medications are missing or damaged during the course of the offsite activity or trip, I release the CBE and any offsite service
provider and its and their respective personnel, trustees, directors, officers, employees, consultants, agents, volunteers and
representatives from any claims, actions, losses, damages, liabilities and costs arising therefrom.
Date Name(pleaseprint) Signature(Parent/LegalGuardian/Independant
Student)
PersonalinformationiscollectedundertheauthorityofAlbertasFreedomofInformationandProtectionofPrivacyAct(FOIP)andtheSchoolAct.Thisinformationwillbeusedtoseeifthecandidate(s)meet
thecriteriaandwillbetreatedinaccordancewiththeprivacyprotectionprovisionsoftheFOIPAct.Ifyouhaveanyquestionsaboutthecollection,contactyourSchoolPrincipalorCorporateRisk
Managementat(403)8177404.
CAN:20964904.3
UpdatedMay2016
Page4of5
https://portal.cbe.ab.ca/service/ose/SitePages/Home.aspx# 4/5
3/23/2017 Off-Site Activities Enhanced - Home
Page4of5
TeacherInCharge: Ross,KathleenA
ServiceProvider(s): NationalMusicCentre
Activities
Departure Return
Activity Location/Destination
(dd/mm/yy) (dd/mm/yy)
NationalMusicCentreFieldTripWordstoSong&Kimball StudioBell8504StreetSECalgary,ABT2G 13/04/17 13/04/17
Performance 1R1
Risks/Hazards
Source Risk
Entiretrip Slips,tripsandfalls
Entiretrip Gettinglostorseparatedfromthegroup
Entiretrip Preexistingmedicalconditions
Entiretrip Weatherconditions
TransportationVehicle Mechanicalfailure
TransportationVehicle PoorDrivingConditions
TransportationVehicle Delay
TransportationVehicle Accidents
Eating Allergies
Eating Choking
UpdatedMay2016
Page5of5
https://portal.cbe.ab.ca/service/ose/SitePages/Home.aspx# 5/5