INFORMED CONSENT/PER

FOR EDUCATIONAL ACTI

All classes will be participating in skating at the Stewart Community Centre every Friday from January 1
Newlands and Mrs. Wark's classes, and from 10:20 - 11:00 for students in Ms. Hare and Mrs. Colbourne's
skating helmet while on the ice. SKATES MUST BE IN A HEAVIER GRADE CLOTH BAG OR HAV
RECOMMENDED THAT STUDENTS WEAR HEAVIER GRADE HAND PROTECTION WHILE SKA
volunteer, you are more than welcome to do so - please contact your child's teacher! Please note: If you ch
office at 613-624-5438.

THIS FORM MUST BE READ AND SIGNED BY THE PARENT/GUARDIAN OF A PARTICIPAT

Educational activity programs, such as

Skating (Ice)
Injuries may occur while participating in these activities. The following list includes, but is not limited t
types of injury which may result from participating in:

Sprains, fractures, dental/head injuries, exposur

The risk of sustaining these types of injuries result from the nature of the activity and can occur without an
facility where the activity is taking place. By choosing to take part in this activity, you are accepting the r

The Upper Canada District School Board does NOT provide accidental death, disability, dismemberment
It is strongly recommended that you purchase Student Accident Insurance, particularly if you do n
sustained in the event of an accident. For additional information on Student Accident Insurance, please
800-463-5437.
Students will travel to this event by

walking

involves certain elements of risk. The following list includes, but is not limited to, examples of the types
transported to
The Stewart Community Centre
Slip, trip, fall, motor vehicle accident, exposure to the weather conditions

*Transportation* When transportation for any trip involves a privately owned vehicle and a volunteer driver (students will no
properly licensed and has sufficient insurance coverage).

Name(s) of volunteer drivers: n/a

We have read the above and we understand and accept that participating in
and travelling by

walking

I give_______________________________________ permission to participate in

(Name of Student)

to be held on

(Date)

Additional student safety/accomodations required for your child:

Name of Parent/ Guardian: (Please Print)____________________________________________________

Signature of Parent/ Guardian:_____________________________________ Date:__________________

Signature of Principal: __________________________________________________________________

INFORMED CONSENT/PERMISSION FORM

FOR EDUCATIONAL ACTIVITY PROGRAMS

ntre every Friday from January 13 to March 10. Skating times will be from
9:40 - 10:20 for students in Mrs.
in Ms. Hare and Mrs. Colbourne's classes. All participants, including adults, must wear a CSA approved ice
GRADE CLOTH BAG OR HAVE SKATE GUARDS TO TRANSPORT TO SCHOOL. IT IS ALSO
AND PROTECTION WHILE SKATING. If you have a current CRC on file at the school and would like to
ld's teacher! Please note: If you child does not have skates, please contact either your child's teacher or the school

GUARDIAN OF A PARTICIPATING STUDENT

Skating (Ice)
g list includes, but is not limited to, examples of the

involve certain elements of risk.

Skating (Ice)
(describe activity)

es, dental/head injuries, exposure to the weather condition

e activity and can occur without any fault of either the student, or the school board, its employees/agents or the
is activity, you are accepting the risk that your child may be injured.

death, disability, dismemberment or medical expense insurance on behalf of the students participating in this activity.
surance, particularly if you do not have a benefit plan through your work, to cover damage, loss and expense
tudent Accident Insurance, please go to the following website http://www.insuremykids.com/about.aspx or call 1Travel by

walking

limited to, examples of the types of injuries which may occur while being

itions

e and a volunteer driver (students will not be permitted to drive other students), the teacher coordinating the event will confirm the driver is

ACKNOWLEDGEMENT

pating in

Skating (Ice)
we are assuming the risks and any associated damage, loss and expense.

articipate in

Skating (Ice)

(Date)

____________________________________________________________

____ Date:_______________________________________

_______________________________________________________

____________________________________________________
Acrobatic Cheerleading
Active Day
Active Strong Kids (ASK)
Archery
Art Club
Athletic Club
Baseball
Basketball
Biking - Mountain
Bear Creek - Outdoor Education Centre
Biking - Paved Surfaces
Board Sailing (Wind Surfing)
Bowling
Broomball (Floor)
Broomball (Ice)
Camp Kawartha
Camp Outdoor Education Centre
Camping - Base Camp
Camping - Residential Camps
Camping - Summer Remote
Camping - Winter
Campus Connections
Canoeing - Flat & Moving Water
Canoeing - White Water
Canoeing - Wilderness Tripping
Climbing - Ascending Lines
Climbing - Bouldering
Climbing - Wall Climbing
Climbing High Ropes
Computer Club
Conference / Seminar
Cricket
Cross Country Running
Curling
Dance/Rhythmic Activities
Design and Tech Workshops
Dog Sledding
Dragon Boating
Ecole de Neige
EMCP
Environmental Sciences - St. Lawrence River Institute
Fencing
Field Trip - Visit another location as a spectator
Field Trip - Walking Excursion
Field Trip - ZigZagZoo

Field Trip to Conservation Area

Field Trip to Farm
Field Trip to Museum
Field Trip to Sugar Bush
Field Trip to Theme Park
Flying - Helicopter/small aircraft
Flying -Commercial airline flight
Football - Flag/Touch
Football - Tackle
Golf
Gymnastics
Hockey - Field
Hockey (Ice)
Hockey/Ringette (Floor)
Horseback Riding
Horseback Riding (Therapeutic Riding)
Ice Fishing
Indoor Playground
Jump Rope for Heart
Kayaking (Flat Water)
Lacrosse
Laser Tag
Luncheon
Maple Sugar Production
Martial Arts (Self Defense)
Mini Golf
Musical Event
Newcombe Ball
Performing Arts (i.e. Drama Performance)
Racquet Sports
Ringette (Ice)
Rowing
Rugby
School Reach Team
School Volunteer Day
Scuba Diving
SEEDS Program
SEVEC Exchange
Skateboarding
Skating (Ice)
Skating (In-line)
Skiing (Downhill) and/or snowboarding
Skiing/Snowshoeing (Cross Country)
Skills Competition
Sledding/Tobogganning (small hill within school yard)
Snow Tubing/Sledding (Large hill or outside of school yard)
Soccer
Softball

Sweat Lodge
Swimming - Camp/Public Beach
Swimming - Hotel Pools
Swimming - Public Pools
Tetherball
Tim Horton's Children's Camp
Tour Boats
Track and Field (multiple events)
Track and Field (Discus)
Track and Field (High Jump)
Track and Field (Hurdles)
Track and Field (Javelin)
Track and Field (Pole Vault)
Track and Field (Running, Triple Jump, Long Jump)
Track and Field (Shot Put)
Track and Field (Softball Throw)
Trampoline (Above Ground)
Trampoline (In ground)
University / College - Open House / Visit
University Sports Day
Volleyball
Water Polo
Winterlude (Snowflake Kingdom)
Workshops
WOW Program - snowshoeing, skating and snowtubing
Wrestling

____________________________________________________
Acrobatic Cheerleading
Active Day
Active Strong Kids (ASK)
Archery
Art Club
Athletic Club
Baseball
Basketball
Biking - Mountain
Bear Creek - Outdoor Education Centre
Biking - Paved Surfaces
Board Sailing (Wind Surfing)
Bowling
Broomball (Floor)
Broomball (Ice)
Camp Kawartha
Camp Outdoor Education Centre
Camping - Base Camp
Camping - Residential Camps
Camping - Summer Remote
Camping - Winter
Campus Connections
Canoeing - Flat & Moving Water
Canoeing - White Water
Canoeing - Wilderness Tripping
Climbing - Ascending Lines
Climbing - Bouldering
Climbing - Wall Climbing
Climbing High Ropes
Computer Club
Conference / Seminar
Cricket
Cross Country Running
Curling
Dance/Rhythmic Activities
Design and Tech Workshops
Dog Sledding
Dragon Boating
Ecole de Neige
EMCP
Environmental Sciences - St. Lawrence River Institute

Fencing
Field Trip - Visit another location as a spectator
Field Trip - Walking Excursion
Field Trip - ZigZagZoo
Field Trip to Conservation Area
Field Trip to Farm
Field Trip to Museum
Field Trip to Sugar Bush
Field Trip to Theme Park
Flying - Helicopter/small aircraft
Flying -Commercial airline flight
Football - Flag/Touch
Football - Tackle
Golf
Gymnastics
Hockey - Field
Hockey (Ice)
Hockey/Ringette (Floor)
Horseback Riding
Horseback Riding (Therapeutic Riding)
Ice Fishing
Indoor Playground
Jump Rope for Heart
Kayaking (Flat Water)
Lacrosse
Laser Tag
Luncheon
Maple Sugar Production
Martial Arts (Self Defense)
Mini Golf
Musical Event
Newcombe Ball
Performing Arts (i.e. Drama Performance)
Racquet Sports
Ringette (Ice)
Rowing
Rugby
School Reach Team
School Volunteer Day
Scuba Diving
SEEDS Program
SEVEC Exchange
Skateboarding
Skating (Ice)
Skating (In-line)
Skiing (Downhill) and/or snowboarding
Skiing/Snowshoeing (Cross Country)

Skills Competition
Sledding/Tobogganning (small hill within school yard)
Snow Tubing/Sledding (Large hill or outside of school yard)
Soccer
Softball
Sweat Lodge
Swimming - Camp/Public Beach
Swimming - Hotel Pools
Swimming - Public Pools
Tetherball
Tim Horton's Children's Camp
Tour Boats
Track and Field (multiple events)
Track and Field (Discus)
Track and Field (High Jump)
Track and Field (Hurdles)
Track and Field (Javelin)
Track and Field (Pole Vault)
Track and Field (Running, Triple Jump, Long Jump)
Track and Field (Shot Put)
Track and Field (Softball Throw)
Trampoline (Above Ground)
Trampoline (In ground)
University / College - Open House / Visit
University Sports Day
Volleyball
Water Polo
Winterlude (Snowflake Kingdom)
Workshops
WOW Program - snowshoeing, skating and snowtubing
Wrestling

____________________________________________________
Fractures, sprains, neck and back injuries
Strains, sprains, fractures, exposure to the weather conditions, head/neck/back injuries
Slip, trip, fall, head/neck/back injuries, fractures and drowning
Pinching of finger, bruising, being struck by an arrow, exposure to the weather conditio
Slip, trip & fall, burns(glue guns), cuts(excato knives)
Strains, sprains, dental injuries, fractures
Fractures, sprains, dental injury, head injury, concussions, exposure to the weather con
Fractures, sprains, neck and back injuries, head injury, concusssions
abrasions, exposure to the weather conditions, fractures, head injury
Fractures, head/neck/back injuries, fall from heights greater than 10 feet, exposure to t
drowning, paralysis

Fractures, abrasions, exposure to the weather conditions

Fractures, head/neck injury, exposure to the weather condition, hypothermia, drowning
Slip & fall, strain
Sprain, fractures, head injury
Sprains, strains, fractures
Fractures, head/neck/back injuries, fall from heights greater than 10 feet, exposure to t
drowning, paralysis

Fractures, head/neck/back injuries, fall from heights greater than 10 feet, exposure to t
drowning, paralysis
exposure to the weather conditions, fractures, sprains
Fractures, sprains, exposure to the weather condition, frostbite, hypothermia
Fractures, sprains, exposure to the weather condition, frostbite, hypothermia
Fractures, exposure to the weather conditions, hypothermia, drowning
Slips, trips, falls, sprain & strains
Fractures, exposure to the weather conditions, hypothermia, drowning
Fractures, exposure to the weather conditions, hypothermia, drowning
Fractures, back injury, exposure to the weather condition, paralysis
Fractures, back injury, paralysis, head injury, fall from heights greater than 30 feet.
Fractures, back injury, exposure to the weather condition, paralysis
Fractures, back injury, paralysis, head injury, fall from heights greater than 30 feet.
Fractures, back injury, paralysis, head injury, fall from heights greater than 30 feet.
Slip & fall, strains, sprains
Slip & fall, strains, sprains
Fractures, dental and/or head injury, exposure to the weather condition
Slip & fall, fractures, sprains, exposure to the weather conditions (heat stroke)
Strains, sprains, head injury
Slip & fall, strains, sprains
slip, trip, fall, sprain, strain and cuts from machinery/hand tools
Fractures, exposure to the weather conditions, hypothermia, drowning, animal bites
Drowning, fractures, exposure to the weather conditions, hypothermia
(Injuries listed are related to all activities) Slip, trip & fall, fractures, sprains, exposure
dental/neck/head/back injuries
Slip & fall, strains, sprains
Slips, trips, falls, sprains, strains and exposure to the weather conditions

Bruises, sprains, cuts, scratches, punctures

Slip & fall, strains, sprains
Slip & fall, strains, sprains, exposure to the weather condition
Sprains, strains, fracture, head/neck/back injuries
Slip & fall, strains, sprains, exposure to weather conditions
Strains, sprains, animal bite, exposure to weather conditions
Slip & fall, strains, sprains
Slip & fall, strains, sprains, animal encounters and exposure to the weather conditions
Dental injury, sprain, slip, trip, fall, exposure to the weather condition, neck and/or bac
Motion sickness, death, terrorism, hijacking,
Motion sickness, death, terrorism, hijacking,
Sprains, strains, fractures, head injury, concussions, exposure to the weather condition
Sprains, fracture, dental/head injuries, exposure to the weather condition
Strains, sprains, dental injuries, exposure to the weather condition
Sprains, fracture, dental/head injuries
Sprains, strains, fractures, exposure to the weather condition
Dental injuries, head/neck/back injuries, fractures,
Sprains, strains, dental/eye injury, fractures
Horse bite and/or kick, fractures, exposure to the weather condition, head/neck/back in
Horse bite and/or kick, fractures, exposure to the weather condition, head/neck/back in
Slip and fall, exposure to the weather conditions, frostbite, hypothermia, falling throug
Slip, trip, fall, strains, sprains
Trip, fall, sprains and strains
Fractures, exposure to the weather conditions, hypothermia, drowning
Fractures, dental injuries, head/neck/back injuries, exposure to the weather condition
Slips, falls, strains and sprains
Slip & fall, strains, sprains
Slip & fall, strains, sprains, exposure to the weather conditions, being struck by falling
liquids

Sprains, strains, broken bones, bruising, head injury, concussions

Slip, trip, fall, strains, sprains, dental injury
Slips, falls, strains and sprains
Strains, sprains and fractures
Slip, trip & fall, strains and sprains
Sprains, fractures, dental injuries
Sprains, fracture, dental/head injuries
Fractures, exposure to the weather conditions, hypothermia, drowning
Sprains, dental/head injury, exposure to the weather condition, fractures
Slip, trip & fall
Slip, trip
Head/neck injuries, drowning
Slips, trips, falls, sprain & strains (Anatomy Program - exposure to preserved human ma
Risks will apply depending on the activities that are planned. See attached
Sprains, fractures, dental/head injuries, exposure to the weather condition
Sprains, fractures, dental/head injuries, exposure to the weather condition
Sprains, fractures, scrapes/cuts, exposure to the weather condition, head injury, concus
Head/neck/back injuries, strains and sprains, exposure to the weather conditions, fractu
Sprains, exposure to the weather conditions, fractures

Slip, trips, falls, cuts and burns from use of machinery/hand tools, abrasions, chemical b
Sprains, dental injuries, head injury, concussions, fractures and exposure to the weathe
Sprains, dental injuries, head injury, concussions, fractures and exposure to the weathe
Trip, fall, sprains, strains, fracture, dental/head injuries, exposure to the weather condi
Sprains, strains, fractures, dental injury, exposure to the weather conditions
Slip, trip, fall, exposure to the weather conditions, increased risk to those with asthma
Possible loss of consciousness and/or nausea.

Head/neck/back injuries, exposure to the weather condition, fractures, drowning

Head/neck/back injuries, fractures, drowning
Head/neck/back injuries, fractures, drowning
Strains, sprains, bruising and strangulation, exposure to the weather condition
Sprains, strains, fractures, head/neck/back injuries, paralysis, being struck by an arrow,
conditions, drowning

Drowning, motion sickness, slip & fall, exposure to the weather condition
Fractures, sprains, strains, exposure to the weather condition
Fractures, sprains, strains, exposure to the weather condition
Fractures, sprains, strains, exposure to the weather condition
Fractures, sprains, strains, exposure to the weather condition
Fractures, sprains, strains, exposure to the weather condition
Fractures, sprains, strains, exposure to the weather condition
Fractures, sprains, strains, exposure to the weather condition
Fractures, sprains, strains, exposure to the weather condition
Fractures, sprains, strains, exposure to the weather condition
Sprains, head/neck/back injuries, fractures, exposure to the weather condition
Sprains, head/neck/back injuries, fractures, exposure to the weather condition
Slip & fall, strains, sprains
Strains, sprains, fractures head/neck/back injuries,dental injuries and drowning (if wate
Strains, sprains and fractures
Head/neck/back injuries, fractures, drowning
Slip & fall, strains, sprains, exposure to the weather conditions
Slip & fall, strains, sprains
Sprains, fractures, dental/head injuries, concussion, exposure to the weather conditions
Sprains, strains, fractures, serious head and neck injury

_____________________________________
airplane
bus
private/rental vehicle
providing their own transportation
walking

Motion sickness, death, terrorism, hijacking

Motor vehicle accident
Motor vehicle accident
Motor vehicle accident
Slip, trip, fall, motor vehicle accident, exposure to the weather conditions