RundleCollegeAcademy
4330-16st SW
Calgary, AB T2T-5K9
Phone: (403) 250-2965 Fax: (403) 250-2614 / Consent of Parent or Guardian
and “Acknowledgement of Risk”
(Off-Site Activity/ies)
BACKGROUND
STUDENT NAME:
  1. Select Both(i) and (ii)
  1.  My Child will be given the opportunity to participate in the following program or activity:Junior High Grade 8 9 Outdoor Environmental Education
a)Name of possible Service Providers: Rundle Academy, Alfred Lake Hunter Training Center, Fish Creek Provincial Park, Kananaskis Country, Southland Transportation, University of Calgary, Mountain Equipment Co-op.
b)Location:Various locations
c)Date: 3th September, 2009 – 14th January 2010
d)Grade(s) Involved: 8 and 9
e)Teacher(s) in Charge: Mr. palmer
f)Cost:$180.00
g)Specific Instructions
SIGNED FORM IS DUE NO LATER THAN:______8th September 2009_____
  1.  My child will be given the opportunity to participate in the following series of off-site activities for the
following program: Possible Field trips to:
  • Alfred Lake Training Center Ricinus Alberta 25th-27th November, 2009 (confirmed)
  • Fish Creek Provincial Park
  • Kananaskis Country
  • Peter Lougheed Provincial park XC skiing/ Snowshoeing 14th January, 2009 (confirmed)
  • RiverParkCalgary
  • Edworthy Park Calgary
  • Weaselhead park Calgary
  • Mountain Equipment Co-op Calgary
  • U of C Outdoor Center
  1. Rundle College Society will make every reasonable effort to ascertain that:
  1. The supervisors and staff of the Service Provider are fully trained and qualified.
  2. The students who undertake the program or activities will be adequately supervised.
  3. The location and/or facilities meet the applicable health and safety standards.
  4. Any equipment made available by the Service Provider or used in the activity has been inspected and is deemed to be appropriate, safe, and well maintained.
  5. The location where the activity will take place is appropriate and safe.
  6. The Service Provider has taken all reasonable steps to ensure that any animal(s) involved in the activity are safe.

Potential hazards may include but are not limited to the following: (if additional space is required, add a separate sheet)
Vehicle travel, physical excursion, Hot/ cold weather, snow/ rain, unpredictable Alberta weather, unstable terrain/ trails, off trail hiking, on trail hiking, rock/ tree fall, animal/ insect hazards, group dynamics, other hiking group hazards, cooking group food, wilderness survival hazards.
Consent and Acknowledgement of Risk
The following means of transportation will be provided:
By: Southland Transportation (or alternative company)
RundleAcademy Van
  1. I accept this mode of transportation for this activity: Yes No
OR
I permit my child to use alternate means of transportation, as identified: Yes No
Other:
(please specify)
  1. I am satisfied that I have been informed of my right to obtain as much information about this program, or activity as I feelnecessary, including information beyond that information provided to me by the school or Rundle College Society to the extent that I require and am not, in any way, relying solely upon information provided by Rundle College Society respecting the nature and extent of the risks and hazards associated with the program or activity.
  1. I freely and voluntarily assume the risks and hazards inherent to the nature of the program or activity and understand and acknowledge that my child, as a participant, may suffer personal and potentially serious injury due to an unforeseeable or fortuitous event.
  1. My child has been informed that he/she is to abide by the rules and regulations including directions and instructions from the school’s administrators, instructors, and supervisors as imposed on students while participating in the program or activities. This shall include his/her participation in all of the introductory sessions and meet all prerequisites prior to his/her participation in the activity or program.
  1. In the event that my child fails to abide by the rules and regulations imposed on the student while participating in the program or activities, disciplinary action may either require that he/she not participate in the program or activity, or that I will be contacted to have him/her picked up, unless I have permitted my child to pursue alternate means of transportation as identified herein.
  1. I acknowledge that it is my responsibility to advise Rundle College Junior High of any medical or health concerns of my child may affect his/her participation in the stated program or activity.
  1. I consent that the Rundle College Society, through its employees, agents, and officers at the school may secure such medical advise and services as those individuals, in their sole discretion, may deem necessary for my child’s health and safety, and that I shall be financially responsible for such advice and services.
  1. Based on my understanding, acknowledgement, and consents as described herein, I agree that
has my permission to participate in this program or activity.
(Name of Student)
Date: Name: Signature:
Trip Emergency Medical Information (Teacher-in-charge will have this information during the Off-Site Activity)
Student Name: Alberta Health No:
Birth Date (optional): Allergies:
Medical Conditions:
Medicine taken (name, reason, dosage):
Other Concerns:
Emergency Contact:1) Phone: (H) (W) (C)
2) Phone: (H) (W) (C)
*MUST BE COMPLETED BY A PARENT OR GUARDIAN
If you have any questions about this consent form, please contact: Mr. Stuart Palmer or
Mr. Holowaychuk, Principal, at250-2965 Address: 4330 - 16 Street SW, Calgary, AB T2T4H9

Forms : Consent Form – Off Site Field Trips