SCHOOL l
Forms
Related Policy:PolicyNo. 603.1 ~ Field/Sports Trips
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D€$Cf.iF>Ii0?!'_ .4 ?ll. 4 Day Trip El FieldTrip Application Form — Low Risk ice: indoor or outdoor rink(not on a /al ‘ El Swimming in a municipal, guarded pool " El Overnight or Out—of—Districtbut within province El FieldTrip Application Form — Moderate Risk E No high—risl l ‘ ' -/fthe I\/lo_d'erate—RiskField/SportsTrips containsanyofthefollowing,alsofr/1’bu'r-thefvollowingforms: Water: in lake (near shore) or near fast moving water Cl Water RiskAssessment Form Swimming in a unguarded or private pool :1 Swimming in an hotel pool/hot tub ‘?gOut—of—Province TripApplicationForm — High Risk High—riskactivity planned: B/FieldRiskAssessment Form forField/Sports Trips Ifthe High—RiskField/SportsTripscontains any ofthe following, alsofilloutthefollowingforms: Water:..lakecrossing or on fast moving water El Water RiskAssessmentForm Ice: on lake only El Ice Risl Name the supervisor identified as the individual on site on the day of the activity, with the authority and responsibility to assess conditi s and th n determine whether or not the acti/Atrytake place.‘ Name: £ Role: V-‘l’ How were supervisors selected? ti hat expertise do they have? r « . .~. I CC‘-«(\CLl\ How were studentsselec ed participate? llf7t’3lCVlC+5 i~ pptlticiaztlct. il . , V What preparation andexperience do have? ‘SllI. reciulcuiq +0 abscessparticipawgstudents‘xp. Are studelitsparticyliatingin supervision? Yes R’No if so, how were students selected to participate in supervision? Describe how paren s/guardians of participants have been fully informed and given their informed consentas per (‘WAY district policy? _ lYl€€lill:.' Risk assessment notes: r /. Signature of principal: /2/1/ Signature of sponsor teacher: Page 1 of1 RiskAssessment Form . Revised: August27, 2016; $eptember9, 2016 Disfrzict»~. V-.. Forms Related Policy: Policy No. 603.1 — Fie/cl/SportsTrips From Administrative Guidelines: Examples ofhigh—riskactivities: - Lakeskating, roller—bIading,ocean kayaking, lake crossing in a canoe, snowboarding, back country skiing, ice/rock climbing, water skiing, parachuting, go—carts, mountain biking, paintball. 0 Out~cif—Province or Out~of-Country High Risk Activity: ‘ 5 Out—of—province Trip involvingwatenEl Other high riskactivity El Out—of—country :1 Trip involving ice El P/ease List: Date ofapplication: school: St 2 (’ccti\<;illPEG lC‘LI\’\c”. Sponsor Teacher(s): x?/if“ I h T‘ ~ —- \ -. ~ Departure date of trip: ._ 4 Departure time: -, Y\\lariousdates (attach a schedule) Return date of trip: Return time: ill(:1}iQ}_’\‘§.»l”\ Give the goals and the educational field trip —— .‘r—identify the sports activity planned: ' ' - ii.bjectives\ofi,t'i\ c _ oh .l Names ofisupervisors in additionto the teacher(s): Number of students participating: it; , Number of adult participants who are not supervising: '|' ,) Type of accommodation: ELLE/' A 1 .‘ Transportation plan: /eJfl\‘_K[ What alternate activity is planned as a substitution in case conditionsdo not allow for original activity to take place, ora student chooses not to participate? Forms to be submitted with this application to the Principal / Vice Principal: Zl Field/Sports Trip RiskAssessment(s) II Participant Roster Please Note: Copies afgj Student Forms and 3 itinerary information Permission Slipsmust be on file at the o?iceprior II Transportation Request(s) to the start ofthe trip. Fie/d/Sports TripApplication Form — High Risk Page 1 of2 Revised: August 27, 2016 3LR‘fl3UL DlS§'Rl {IT 15 % Forms ;——.= To Be Completed by Principal / Vice Principal Activity Assessed as HIGH RISK: ?es RiskAssessment completed by: RiskAssessment notes: Student supervision — and —transportation plans meet policy requirements? Mes Allvolunteer supervisors are in compliance with policy1002.3? ‘Q/Yes is Parental Informed Consent Process complete? es Forms to be completed and originals to be filed at your school: B/‘Field/SportsTrip RiskAssessment(s) at Up-to-Sate Participant Roster itinerary l.7.l‘Transportation Request(s) if arental informedconsent record lI(:tudentinformation Forms / Permission Slips If out-of—countm, also file the following originals at y_qurschool: IE/GlroupMedical/HospitalInsurance coverage Cl Trip Cancellation insurance ***Theseformsmay be arranged by a tour company [3 ChildTravel Consent Forms El Permission Slipsfor Treatment by a Doctor in a Foreign County Forms to be submitted to the BoardOffice for BOARDAPPROVALonce the above paperwork is completed: B COPYof this form - signed 13 COPYof the Field/SportsTrip Risk'Assessment(s) El COPYof the itinerary Comments: Principal/Vice Principalsignaturez I . Dates t°"l K Dateof Board Approval: Date school informed of approval: Via: E|_E-mailBy: El Phone By: 4 ” Ou-of—Country'—To BeCompleted y hool Bar OffceaWekBeforethe Departr Date Travel Advisory Report: Signature of Superintendent, or designate: : _ Date:‘ Field/Sports Trip Application Form ~ High Risk P0992 Of? ' Revised: August 27, 2016 ' o2..§.£mo - 1 - .om”2.o92 oma Oouo omumm oz?a .5 ?n 35 ow: 8.: c?és 5%: 5:5 nz?mu E: GE 6:5 EmmaADUSE ??m . c332 Scam 00.3 : comm 3,50 55.2 H>?A.mu . 3msSn...:2 - omuww. I + $55. . omuwoonm m owe - mu ®5..swm.«E .omno oo uA m~mawuHu”m..~w_m?~maw%~&yuuw%~_u%u..&.Eo?muuu MEEEO E .a.:n «.8 “Emu?KQHH #30 . . . ounmv?mxmE..:._::o :mE.3O 223,9 ADVGEuvzdm. cad, - oo Ho mumno 22¢ By 828. o?m?um owe- c Game535 . . . ooum S . Eam oo..m- only 95» - ooh P?swm . AD . u - . . Szsm 332 BSSQM ooh ooh - o omum mccw:S..w:wnm,ES- a?m~mwmm.ww_“mcwH:oau. Ea 58 $3 oo.m ooé £2 5 P550 2 62¢. . U S 35.5. umQwm?ém anong ~EuE>o.£ uwmm?o?wao wca?wmh. nwao?mm?o 950 . . 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