Parental Information/Medical Info

A. PARENTAL INFORMATION
School: Pakenham Public School

Destination of Trip: Mount Pakenham

Departure Date & Time: February 8, 2017, 9:30 a.m.

Method of Transportation:
*Transportation* When transportation for any trip involves a privately owned vehicle and a volunteer driver (students will not be permitted to drive other students), the teache
the driver is properly licensed and has sufficient insurance coverage.

Teacher in Charge: D. Balfour

Educational activity programs, such as WOW Program - snowshoeing, skating and snowtub
Injuries may occur while participating in these activities. The following list includes, but is not limited to, example
types of injury which may result from participating in:

Sprains, fractures, dental/head injuries, concussion, exposure to t

Additional Equipment Required: outdoor

*In the event this activity is cancelled, participants will be notified (school web site, radio broadcast, letter to parents, etc.). A refund will be
B. MEDICAL INFORMATION Please complete, detach and return to the school

Student: ________________________________________________________________________

Parent/Guardian: ____________________________________

Additional contact (in the event you are not available): Name: _________________________________________

Medical Condition/ Information provided on this form will be used to make decisions concerning your child's
not intended to limit level of participation.
Please indicate any significant medical conditions, physical limitations, or any other concerns which may require atten
Asthma Fainting Spells
Allergies Feet or Leg problems
Chronic Nosebleed Bleeding disorders
Diabetes Heart problems
Digestive upsets Hernia
Drug Sensitivity History of head injuries
Ear/Nose/Throat infections Migraines

Give details of history/usual treatment for each of the above conditions indicated: ____________________________
Please explain if your child has any other medical condition/treatment that we should be aware of:________________
______________________________________________________________________________________________
Allergies/Asthma
Has your child suffered any serious allergic or asthmatic reaction?
If so, please provide details, including the type and severity of reaction: Mild____ Moderate____ Serious____ L
Has a doctor prescribed an Epi-Pen for your child? Yes____ No____
Has a doctor prescribed an inhaler? Yes____ No___ (Prescribed asthma inhalers must be carried by the student on th

I, ________________________________, confirm the information on file with the school my child attends is the mo
Signature of Parent/Guardian:______________________________________________________________________

Should it become necessary for my child/ward to have medical care, I hereby give the teacher permission to us
such service for my child/ward. I also understand that in the event of such illness or accident, I will be notified
sign this section if they agree with the above statement)
Name of Parent/Guardian: ________________________________________________________________________

Signature of Parent/Guardian: __________________________________________________________Date: _______

 Parental Information/Medical Information Form

ham Public School Phone Number: 613-624-5438

Mount Pakenham Students Cost: See attached

February 8, 2017, 9:30 a.m. Return Date & Time: Feb. 8, 3:00 p.m.

d a volunteer driver (students will not be permitted to drive other students), the teacher coordinating the event will confirm the name of the driver, that
iver is properly licensed and has sufficient insurance coverage.

D. Balfour Emergency Contact #: _______________________

613-624-5438

WOW Program - snowshoeing, skating and snowtubing involve certain elements of risk.
The following list includes, but is not limited to, examples of the
WOW Program - snowshoeing, skating and snowtubing
(describe activity)
actures, dental/head injuries, concussion, exposure to the weather conditions

outdoor wear, lunch

ol web site, radio broadcast, letter to parents, etc.). A refund will be provided whenever possible.
ch and return to the school

_______________________________

Telephone: (H) __________________________ (B)____________________________

e: _________________________________________ Telephone: ______________________________

will be used to make decisions concerning your child's health during the activity/excursion, information is

limitations, or any other concerns which may require attention during this activity/excursion;
Rash Dislocated shoulder; swollen, painful joints;
Recent illness or operation trick or lock knee or other joint disability
Rheumatic Fever
Seizures Other:
Sleepwalking
Urinary infections

conditions indicated: ________________________________________________________

treatment that we should be aware of:___________________________________________
____________________________________________________________________

of reaction: Mild____ Moderate____ Serious____ Life-Threatening____

ribed asthma inhalers must be carried by the student on the excursion.)

mation on file with the school my child attends is the most up to date medical information.
________________________________________________________________

edical care, I hereby give the teacher permission to use her/his best judgment in obtaining the best of
the event of such illness or accident, I will be notified as soon as possible. (parents/guardians should only

____________________________________________________(Please print)

___________________________________Date: _______________________
613-624-5438

See attached

eb. 8, 3:00 p.m.

613-624-5438
____________________________________________________
Acrobatic Cheerleading
Active Day
Active Strong Kids (ASK)
Archery
Art Club
Athletic Club
Baseball
Basketball
Bear Creek - Outdoor Education Centre
Biking - Mountain
Biking - Paved Surfaces
Biodome
Board games/gaming
Board Sailing (Wind Surfing)
Bowling
Broomball (Floor)
Broomball (Ice)
Camp Kawartha
Camp Outdoor Education Centre
Camping - Base Camp
Camping - Residential Camps
Camping - Summer Remote
Camping - Winter
Campus Connections
Canoeing - Flat & Moving Water
Canoeing - White Water
Canoeing - Wilderness Tripping
Climbing - Ascending Lines
Climbing - Bouldering
Climbing - Wall Climbing
Climbing High Ropes
Computer Club
Conference / Seminar
Cricket
Cross Country Running
Curling
Dance/Rhythmic Activities
Design and Tech Workshops
Dog Sledding
Dragon Boating
Ecole de Neige
EMCP
Environmental Sciences - St. Lawrence River Institute
Fencing
Field Trip - Walking Excursion
Field Trip to Conservation Area
Field Trip to Farm
Field Trip to historic site/park
Field Trip to Museum
Field Trip to Sugar Bush
Field Trip to Theme Park
Field Trip to visit another location as a spectator
Field Trip to ZigZagZoo
Flying - Helicopter/small aircraft
Flying -Commercial airline flight
Football - Flag/Touch
Football - Tackle
Glass Blowing
Golf
Gymnastics
Hockey - Field
Hockey (Ice)
Hockey/Ringette (Floor)
Horseback Riding
Horseback Riding (Therapeutic Riding)
Ice Fishing
Indoor Playground
Jump Rope for Heart
Kayaking (Flat Water)
Lacrosse
Laser Tag
Luncheon
Maple Sugar Production
Martial Arts (Self Defense)
Mini Golf
Musical Event
Newcombe Ball
Performing Arts (i.e. Drama Performance)
Racquet Sports
Ringette (Ice)
Rowing
Rugby
School Reach Team
School Volunteer Day
Scuba Diving
SEEDS Program
SEVEC Exchange
Skateboarding
Skating (Ice)
Skating (In-line)
Skiing (Downhill) and/or snowboarding
Skiing/Snowshoeing (Cross Country)
Skills Competiton
Sledding/Tobogganning (small hill within school yard)
Snow Tubing/Sledding (Large hill or outside of school yard)
Soccer
Softball
Sweat Lodge
Swimming - Camp/Public Beach
Swimming - Hotel Pools
Swimming - Public Pools
Tetherball
Tim Horton's Children's Camp
Tour Boats
Track and Field (multiple events)
Track and Field (Discus)
Track and Field (High Jump)
Track and Field (Hurdles)
Track and Field (Javelin)
Track and Field (Pole Vault)
Track and Field (Running, Triple Jump, Long Jump)
Track and Field (Shot Put)
Track and Field (Softball Throw)
Trampoline (Above Ground)
Trampoline (In ground)
University / College - Open House / Visit
University Sports Day
Volleyball
Water Polo
Winterlude (Snowflake Kingdom)
Workshops
WOW Program - snowshoeing, skating and snowtubing
Wrestling
____________________________________________________
Acrobatic Cheerleading
Active Day

Active Strong Kids (ASK)

Archery

Art Club
Athletic Club
Baseball

Basketball
Bear Creek - Outdoor Education Centre

Biking - Mountain
Biking - Paved Surfaces
Biodome
Board games/gaming
Board Sailing (Wind Surfing)

Bowling
Broomball (Floor)
Broomball (Ice)
Camp Kawartha

Camp Outdoor Education Centre

Camping - Base Camp

Camping - Residential Camps
Camping - Summer Remote
Camping - Winter
Campus Connections
Canoeing - Flat & Moving Water
Canoeing - White Water
Canoeing - Wilderness Tripping
Climbing - Ascending Lines
Climbing - Bouldering
Climbing - Wall Climbing
Climbing High Ropes
Computer Club
Conference / Seminar
Cricket
Cross Country Running
Curling
Dance/Rhythmic Activities
Design and Tech Workshops
Dog Sledding
Dragon Boating
Ecole de Neige

EMCP
Environmental Sciences - St. Lawrence River Institute
Fencing
Field Trip - Walking Excursion
Field Trip to Conservation Area
Field Trip to Farm
Field Trip to historic site/park
Field Trip to Museum
Field Trip to Sugar Bush
Field Trip to Theme Park
Field Trip to visit another location as a spectator
Field Trip to ZigZagZoo
Flying - Helicopter/small aircraft
Flying -Commercial airline flight
Football - Flag/Touch
Football - Tackle
Glass Blowing
Golf
Gymnastics
Hockey - Field
Hockey (Ice)
Hockey/Ringette (Floor)
Horseback Riding
Horseback Riding (Therapeutic Riding)
Ice Fishing
Indoor Playground
Jump Rope for Heart
Kayaking (Flat Water)
Lacrosse
Laser Tag
Luncheon
Maple Sugar Production

Martial Arts (Self Defense)

Mini Golf
Musical Event
Newcombe Ball
Performing Arts (i.e. Drama Performance)
Racquet Sports
Ringette (Ice)
Rowing
Rugby
School Reach Team
School Volunteer Day
Scuba Diving
SEEDS Program

SEVEC Exchange
Skateboarding
Skating (Ice)
Skating (In-line)
Skiing (Downhill) and/or snowboarding

Skiing/Snowshoeing (Cross Country)

Skills Competiton
Sledding/Tobogganning (small hill within school yard)

Snow Tubing/Sledding (Large hill or outside of school yard)

Soccer

Softball
Sweat Lodge

Swimming - Camp/Public Beach

Swimming - Hotel Pools
Swimming - Public Pools
Tetherball
Tim Horton's Children's Camp

Tour Boats
Track and Field (multiple events)
Track and Field (Discus)
Track and Field (High Jump)
Track and Field (Hurdles)
Track and Field (Javelin)
Track and Field (Pole Vault)
Track and Field (Running, Triple Jump, Long Jump)
Track and Field (Shot Put)
Track and Field (Softball Throw)
Trampoline (Above Ground)
Trampoline (In ground)
University / College - Open House / Visit
University Sports Day

Volleyball
Water Polo
Winterlude (Snowflake Kingdom)
Workshops
WOW Program - snowshoeing, skating and snowtubing

Wrestling
____________________________________________________
Fractures, sprains, neck and back injuries
Strains, sprains, exposure to the weather conditions, fractures head/neck/back injuries
and dental injuries
Slip, trip, fall, head/neck/back injuries, fractures and drowning (if swimming is involved).

Pinching of finger, bruising, being struck by an arrow, exposure to the weather condition

Slip, trip & fall, burns(glue guns), cuts(excato knives)

Strains, sprains, dental injuries, fractures
Fractures, sprains, dental injury, head injury, concussions, exposure to the weather
conditions
Fractures, sprains, neck and back injuries, head injury, concusssions
Fractures, head/neck/back injuries, fall from heights greater than 10 feet, exposure to
the weather conditions, drowning, paralysis
abrasions, exposure to the weather conditions, fractures, head injury
Fractures, abrasions, exposure to the weather conditions
Slip & fall, strains, sprains, animal encounters and exposure to the weather conditions
Slips, trips, falls, sprain & strains
Fractures, head/neck injury, exposure to the weather condition, hypothermia, drowning

Slip & fall, strain

Sprain, fractures, head injury
Sprains, strains, fractures
Fractures, head/neck/back injuries, fall from heights greater than 10 feet, exposure to
the weather conditions, drowning, paralysis
Fractures, head/neck/back injuries, fall from heights greater than 10 feet, exposure to
the weather conditions, drowning, paralysis
exposure to the weather conditions, fractures, sprains
Fractures, sprains, exposure to the weather condition, frostbite, hypothermia
Fractures, sprains, exposure to the weather condition, frostbite, hypothermia
Fractures, exposure to the weather conditions, hypothermia, drowning
Slips, trips, falls, sprain & strains
Fractures, exposure to the weather conditions, hypothermia, drowning
Fractures, exposure to the weather conditions, hypothermia, drowning
Fractures, back injury, exposure to the weather condition, paralysis
Fractures, back injury, paralysis, head injury, fall from heights greater than 30 feet.
Fractures, back injury, exposure to the weather condition, paralysis
Fractures, back injury, paralysis, head injury, fall from heights greater than 30 feet.
Fractures, back injury, paralysis, head injury, fall from heights greater than 30 feet.
Slip & fall, strains, sprains
Slip & fall, strains, sprains
Fractures, dental and/or head injury, exposure to the weather condition
Slip & fall, fractures, sprains, exposure to the weather conditions (heat stroke)
Strains, sprains, head injury
Slip & fall, strains, sprains
Slip, trip, fall, sprain, strain and cuts from machinery/hand tools
Fractures, exposure to the weather conditions, hypothermia, drowning, animal bites
Drowning, fractures, exposure to the weather conditions, hypothermia
(Injuries listed are related to all activities) Slip, trip & fall, fractures, sprains, exposure
to the weather conditions, dental/neck/head/back injuries
Slip & fall, strains, sprains
Slips, trips, falls, sprains, strains and exposure to the weather conditions
Bruises, sprains, cuts, scratches, punctures
Slip & fall, strains, sprains, exposure to the weather condition
Slip & fall, strains, sprains, exposure to weather conditions
Strains, sprains, animal bite, exposure to weather conditions
Slip & fall, strains, sprains, exposure to weather conditions, possible animal bite and drow
Slip & fall, strains, sprains
Slip & fall, strains, sprains, animal encounters and exposure to the weather conditions
Dental injury, sprain, slip, trip, fall, exposure to the weather condition, neck and/or back in
Slip & fall, strains, sprains
Sprains, strains, fracture, head/neck/back injuries
Motion sickness, death, terrorism, hijacking,
Motion sickness, death, terrorism, hijacking,
Sprains, strains, fractures, head injury, concussions, exposure to the weather condition
Sprains, fracture, dental/head injuries, exposure to the weather condition
Burns, exposure to fire and hots materials, cuts from glass, potential for unexpected explo
Strains, sprains, dental injuries, exposure to the weather condition
Sprains, fracture, dental/head injuries
Sprains, strains, fractures, exposure to the weather condition
Dental injuries, head/neck/back injuries, fractures,
Sprains, strains, dental/eye injury, fractures
Horse bite and/or kick, fractures, exposure to the weather condition, head/neck/back injur
Horse bite and/or kick, fractures, exposure to the weather condition, head/neck/back injur
Slip and fall, exposure to the weather conditions, frostbite, hypothermia, falling through ic
Slip, trip, fall, strains, sprains
Trip, fall, sprains and strains
Fractures, exposure to the weather conditions, hypothermia, drowning
Fractures, dental injuries, head/neck/back injuries, exposure to the weather condition
Slips, falls, strains and sprains
Slip & fall, strains, sprains
Slip & fall, strains, sprains, exposure to the weather conditions, being struck by falling
branches, burn from boiling liquids
Sprains, strains, broken bones, bruising, head injury, concussions
Slip, trip, fall, strains, sprains, dental injury
Slips, falls, strains and sprains
Strains, sprains and fractures
Slip, trip & fall, strains and sprains
Sprains, fractures, dental injuries
Sprains, fracture, dental/head injuries
Fractures, exposure to the weather conditions, hypothermia, drowning
Sprains, dental/head injury, exposure to the weather condition, fractures
Slip, trip & fall
Slip, trip & fall
Head/neck injuries, drowning
Slips, trips, falls, sprain & strains (Anatomy Program - exposure to preserved human
materials
Risks will apply depending on the activities that are planned. See attached
Sprains, fractures, dental/head injuries, exposure to the weather condition
Sprains, fractures, dental/head injuries, exposure to the weather condition
Sprains, fractures, scrapes/cuts, exposure to the weather condition, head injury, concussio
Head/neck/back injuries, strains and sprains, exposure to the weather conditions,
fractures, collisions
Sprains, exposure to the weather conditions, fractures
Slip, trips, falls, cuts and burns from use of machinery/hand tools, abrasions, chemical bur
Sprains, dental injuries, head injury, concussions, fractures and exposure to the weather
conditions
Sprains, dental injuries, head injury, concussions, fractures and exposure to the weather
conditions
Trip, fall, sprains, strains, fracture, dental/head injuries, exposure to the weather
conditions
Sprains, strains, fractures, dental injury, exposure to the weather conditions
Slip, trip, fall, exposure to the weather conditions, increased risk to those with asthma
and cardivascular conditions. Possible loss of consciousness and/or nausea.
Head/neck/back injuries, exposure to the weather condition, fractures, drowning
Head/neck/back injuries, fractures, drowning
Head/neck/back injuries, fractures, drowning
Strains, sprains, bruising and strangulation, exposure to the weather condition
Sprains, strains, fractures, head/neck/back injuries, paralysis, being struck by an arrow,
exposure to the weather conditions, drowning
Drowning, motion sickness, slip & fall, exposure to the weather condition
Fractures, sprains, strains, exposure to the weather condition
Fractures, sprains, strains, exposure to the weather condition
Fractures, sprains, strains, exposure to the weather condition
Fractures, sprains, strains, exposure to the weather condition
Fractures, sprains, strains, exposure to the weather condition
Fractures, sprains, strains, exposure to the weather condition
Fractures, sprains, strains, exposure to the weather condition
Fractures, sprains, strains, exposure to the weather condition
Fractures, sprains, strains, exposure to the weather condition
Sprains, head/neck/back injuries, fractures, exposure to the weather condition
Sprains, head/neck/back injuries, fractures, exposure to the weather condition
Slip & fall, strains, sprains
Strains, sprains, fractures head/neck/back injuries,dental injuries and drowning (if water
activities are involved)
Strains, sprains and fractures
Head/neck/back injuries, fractures, drowning
Slip & fall, strains, sprains, exposure to the weather conditions
Slip & fall, strains, sprains
Sprains, fractures, dental/head injuries, concussion, exposure to the weather conditions

Sprains, strains, fractures, serious head and neck injury

and drowning (when exposures are present)

or back injury.

cted explosions.

back injuries
back injuries
through ice, drowning
concussions

mical burns, allergic reactions

bus,
not required
other___________________,
private/rental vehicle,
walking,
Motor vehicle accident
Not applicable
(list type of injuries)
Motor vehicle accident
Slip, trip, fall, motor vehicle accident, abduction, exposure to the elements