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HICA Sample Consent Form For Field Trips/Excursions (In & Out Of Province) - Exhibit 4


Student’s Name:_________________________________________________________


Homeroom:_________________________________________________________


Note To Parents:

Please read the contents of this consent form before signing it. If you have any concerns regarding the arrangements for supervision, DO NOT CONSENT TO YOUR CHILD’S PARTICIPATION. If this consent form is not signed and returned to the school by <insert date>, your child WILL NOT BE ALLOWED TO ATTEND.

Authorization:

I/WE understand that the School District (hereinafter called “the Board” which term shall include the Board’s successors and assigns, principals, teachers, duly appointed chaperons, employees, and their heirs, executors and assigns) arranges, excursions or tours which, in the opinion of the Board, have definite educational, athletic, or cultural value and are an integral part of the Board’s program.

I/WE, being the parent(s) or guardian(s) of _____________________________ (hereinafter called “the student”) consent to the student participating in any such tours or excursions arranged by the Board, and we authorize the participation by the student. It is understood that my/our consent and authorization are subject to the following conditions:

  1. The Board accepting responsibility for any injuries or damages which may be suffered by the student while involved in any such tour or excursion which results from the negligence of the Board.
  2. I hereby authorize any of the adult supervisors on the tour or excursion to consent to any medical attention the student requires between <insert date>, and to make any arrangements they feel are required for special transportation (for example, transport by ambulance)
  3. I assume all the responsibility for the costs, as A.H.I.C., Blue Cross, etc. may be limited (ie., in foreign countries) and which can be expanded by additional private insurance for sickness and hospital expenses.  I/we acknowledge that additional  insurance for students coverage is a parental responsibility, especially as problems arise where no negligence is apparent.
  4. The Board (usually the school) advising we/us in writing of the following particulars of any tour or excursion at least three school days prior to the intended date of the tour or excursion:
    Description of Tour or Excursion:
    1. destination;
    2. arranged supervision;
    3. date(s) and time(s);
    4. transportation plans;
    5. costs, if any; and
    6. an Alberta telephone number through which additional information on the tour or excursion may be obtained.
  5. Description of Supervision:
    Adult supervisors will supervise the students:
    1. on the bus to and from <destination>.
    2. <any other details to be filled in by school, if applicable>

      The students will not be supervised while skiing at <destination>, although adult supervisors will be at <destination>. The students will be treated as any other skier at<destination>, subject only to the level of supervision provided by <destination> staff to any other skier. (SAMPLE ONLY)
  6. My/our having the right to advise the Board, in writing, at least two school days before the commencement of any particular tour or excursion, that I/we do not consent to the student participating in the tour or excursion, in which event my/our consent and authorization will be considered as withdrawn for the particular tour or excursion and the student shall not be allowed by the Board to participate in such tour or excursion.
  7. This consent and authorization will be in effect for the current school year only.

Conditions:

  1. Students and parents accept that teachers and others designated as chaperones will be in complete charge of the students. The students are directly answerable to the chaperones for the duration of the trip.
  2. Drinking of alcoholic beverages, regardless of age, and/or possession of drugs is not permitted and could result in an immediate return home at the expense of the parent, guardian, or independent student.
  3. Students are expected to conduct themselves in a responsible manner, keeping in mind that they are acting as representatives of the school and the city.
  4. Medical information has been provided.
  5. In case of loss or theft of the original: (applies only to out-of-province field trips/excursions).
    1. Travel to the United States: A copy of the student’s Birth Certificate must be given to the supervisor.
    2. Travel Overseas: A copy of the student’s Passport must be given to the supervisor.


I have read, understood and agree to abide by the conditions listed above:


Student Name: _________________________________________________________


Student Signature: ______________________________________________________


Student Medical Alerts: __________________________________________________


Student Health Card Number: _____________________________________________

 

I hereby grant permission for my son/daughter to participate in the activity noted above.

Information about the purpose of the trip, the supervision, transportation, and other arrangements has been provided to me. I have read, understood and agree to the conditions as outlined.


Date:    ___________________________________



Signature of Parents/Guardians: _____________________________________________________________

(Obtain both signatures if it is practical to do so)


Home Telephone Number: ___________________


Business Telephone Number: _________________




Thank you. I do not wish my child to participate in the field trip.


Date: ________________________


Signature of Parents/Guardians: _____________________________________________________________

(Obtain both signatures if it is practical to do so)



Prepared for USIC by: Aon Reed Stenhouse

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