Consent of VOLUNTEER and

Acknowledgement of Risk for A and B

Off-Site Activity/ies
Risk and Insurance Management
PLEASE READ CAREFULLY
VOLUNTEER NAME:

SCHOOL: University School

1. Select either (i) or (ii)

(i)

I will be given the opportunity to participate in the following program or activity: (please specify program)
Grade 5 Off-Site Activity to the Fairview Hutterite Colony
a) Name of the Service Provider: Fairview Hutterite Colony

(ii)

2.

b) Location:

Box 1234 Crossfield, AB. T1T 1T1

c) Date:

April 5, 2016

d) Teacher in Charge:

Alanna Kennard

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.
The CBEs 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

Forms A Z
RM - Consent of VOLUNTEER and Acknowledgement of Risk A & B Off-Site Activities

April 2012
Page 1 of 3

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:
Outdoor allergies, such as pollens, grasses, insects or bee stings. The terrain maybe uneven at times. The colony is
located outside of Crossfield, in case of an emergency the nearest hospital is located approximately 20 kilometres from
the facility. We will be taking a school bus to and from the colony which will involve city and country road travel. The
wather can be brisk in spring, so it is unpredictable if it may snow or rain.

4. The following means of transportation will be provided by: Southland Transportation Ltd.
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 post 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 advice 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.

Date:

Name:

Signature:
Volunteer (please print)

Forms A Z
RM - Consent of VOLUNTEER and Acknowledgement of Risk A & B Off-Site Activities

_______
Volunteer

April 2012
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MEDICAL INFORMATION
For Volunteers
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
Activity: Grade 5 Fairview Hutterite Colony

Date(s) April 5, 2016

Name of Volunteer:

Alberta Health Care # (Optional):

Date of Birth (Yr/M/D):

Allergies:

Do you have any Allergies?

Drug Allergies?

Yes

No

Food Allergies?

Yes

No

Insect Allergies?

Yes

No

Other Allergies?

Yes

No

Medical Conditions
Are you under any form of treatment for an
illness, condition or injury? (including Asthma)

Yes

Yes

No If YES, please specify below.

If yes, please elaborate. Include activities to be restricted or modified.

No

Please fill out the medication names and details for administering them: (if more space is required please attach additional information)
NAME OF MEDICATION

REASON (OPTIONAL)

DOSAGE

HOW OFTEN?

TIME OF DAY

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

Dietary Restrictions (if any):
Additional Instructions/Information:
Emergency Contact: 1)

Phone:

(H)

(W)

(C)

2)

Phone:

(H)

(W)

(C)

The above Medical information is accurate to the best of my knowledge.

Signature of Volunteer::
Name of Volunteer:
(Please Print)
Personal information is collected under the authority of Albertas 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 Risk and Insurance Management at 403-817-7407.

Forms A Z
RM - Consent of VOLUNTEER and Acknowledgement of Risk A & B Off-Site Activities

April 2012
Page 3 of 3