Calgary Board of Education

Consent of VOLUNTEER and “Acknowledgement of Risk” for “A” and “B”

Off-Site Activity/iesCorporate Risk Management

PLEASE READ CAREFULLY VOLUNTEER NAME: SCHOOL: Terry Fox Jr. High

1. Select either (i) or (ii)

(i) I will be given the opportunity to participate in the following program or activity: (please specify program)Band Workshop at Camp Caroline

a) Name of the Service Provider: Hal Gericke, program manag er b) Location: Rge Rd 61 Caroline, AB TOM OMO c) Date: Sep. 9-11, 2009 d) Teacher in Charge: Adam Mailman

(ii) I will be given the opportunity to participate in the following series of off-site activities for the following program. (please specify program)

*SEE THE ATTACHED LIST FOR ACTIVITIES, DATE, LOCATION, SERVICE PROVIDER AND TEACHER IN CHARGE. 2. The CBE’s Expectations for Volunteers

Volunteers are part of the supervision of an off-site activity and are expected to: Review and comply with the requirement of Policy 5003 – Volunteers (Volunteer Registration) Have qualifications appropriate for the off-site activity Are expected to know the details of the off-site activity and their specific duties and authority prior to departure Exhibit positive behaviour and be an acceptable role model Must support and follow the school code of conduct Report any inappropriate conduct to the teacher-in-charge Adhere to the schedule or itinerary Dress appropriately for the off-site activity Fulfil their duties as supervisors for the duration of the off-site activity, including evening and weekends

CONSENT AND ACKNOWLEDGEMENT OF RISK

3. Potential hazards and risks of the Off-Site Activity may include but are not limited to financial loss, illness, injury or death. I acknowledge the existence of known risks and potential unknown risks and I voluntarily assume the risks which may include, but are not limited to:Transportation: vehicle accident - associated injuries Allergies: allergic reaction to food provided Walking on grounds: personal injury including sprains, strains, minor cuts and bruises, broken bones

Forms A – Z RM - Consent of VOLUNTEER and “Acknowledgement of Risk” – “A” & “B” Off-Site Activities November 2008

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4. The following means of transportation will be provided by: National Motor Coach

5. I accept this mode of transportation for this activity: OR

I will provide my own mode of transportation,:OR

I consent to the use of my vehicle for the transportation of student for this activity.AND

I have completed the Volunteer Driver Application

Yes No

Yes No

Yes No

Yes No

6. I am satisfied that I have been informed of my right to obtain as much information about this program, or activity as I feel necessary, including information beyond that provided to me by the school or Board to the extent that I require and am not, in any way, relying solely upon information provided by the Calgary Board of Education respecting the nature and extent of the risks and hazards associated with the program or activity.

7. I freely and voluntarily assume the risks and hazards inherent in the nature of the program or activity and understand and acknowledge that I, as a volunteer, may suffer personal and potentially serious injury due to an unforeseeable or fortuitous event.

8. If required I will participate in any preparatory and pose sessions associated with this activity or program.

9. I acknowledge that it is my responsibility to advise the CBE of any medical or health concerns which may affect my participation in the stated program or activity.

10. I consent that the CBE, 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 health and safety, and that I shall be financially responsible for such advice and services.

Forms A – Z RM - Consent of VOLUNTEER and “Acknowledgement of Risk” – “A” & “B” Off-Site Activities November 2008

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IMPORTANT – MEDICAL INFORMATION

Health Information: (Teacher-in-Charge will have a photocopy of this information during the Off-Site Activity/ies to address health and medical needs including emergencies and may share this information with others as deemed necessary.)

MUST BE COMPLETED

Volunteer Name: AHC#: (Required if trip is outside Alberta)

Birth Date: Allergies:

Medical Conditions:

Medications taken (name, reason, dosage)

Medical Treatment Restrictions (if any) e.g. blood transfusions:

Dietary Restrictions (if any):

Other Concerns:

Emergency Contact: 1) Phone: (H) (W) (C)

2) Phone: (H) (W) (C)

I understand and consent to the above as described herein:

Date: Name: (Please Print)

Signature:

Personal information is collected under the authority of Alberta’s Freedom of Information and Protection of Privacy Act (FOIP) and the School Act. This information will be used to see if the candidate(s) meet the criteria and will be treated in accordance with the privacy protection provisions of the FOIP Act. If you have any questions about the collection, contact your school principal or Corporate Risk Management at 403-294-8578.

Forms A – Z RM - Consent of VOLUNTEER and “Acknowledgement of Risk” – “A” & “B” Off-Site Activities November 2008

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