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Form 511C
Aug. 30, 2004
Page 1 of 2
Parent/Guardian Permission for Excursion
The collection and retention of the information requested on this form is authorized and governed
by the Ontario Education Act and the Municipal Freedom of Information and Protection of Privacy Act.
School: Deer Park Jr & Sr P.S. Telephone: 416-393-1550
Teacher(s): Ms. Budd, Mr. Mann, Mr. Hockin, Ms. Sequinot, Ms. Downie, Mr. Gorczynski Grade/Class: 7
Student: Date of Excursion: May 30th—June 3rd
Nature of Activity: Grade 7 Camp Trip
Destination: __Camp Wahanowin – Orillia, Ontario
To Parents and Guardian:
The purpose of this form is to inform you about the excursion and to seek your support and permission for your child/ward to
participate. This information may be shared as necessary with adults supervising the excursion.
This is an important document. Please ensure that someone is able to translate and explain this document to you.
Purpose of the excursion: Team building, character education, Science/Geography/Physical Education curriculum enhancement
Itinerary
Program/itinerary: Variety of activities that may include but not limited to archery, fishing, kayaking, cooking, outdoor games, ropes
course, arts and crafts, drama, nature walks
Departure from School: Date Monday May 30th Time 11:00 a.m.
rd
Return to School: Date Friday June 3 Time 3:30 p.m.
In exceptional circumstances, dates and times may change. Every effort will be made to communicate these changes to you ahead of time.
Method of Travel
TDSB bus Public transit ____Commercial vehicle
X Private vehicle(adult driver)* Private vehicle(Student driver)*
*Approval of the principal is required for all volunteer drivers. The school will make every effort to ensure that parent/guardian consent is obtained for each excursion
for students to travel in private vehicles.
Requirements for Participants
Food/snacks: Lunch on Monday Money: Optional: Tuck shop available after dinner
Notebook: NA Clothing and equipment: List to follow
Other:
As part of the excursion, students will be participating in the following high-care activities. These activities involve increased risk or
special safety considerations, or require special qualifications or certification for supervision. Appropriate supervision will be
provided. Team ropes or High ropes, kayaking/canoeing, lake swimming
Accommodation (if required)__Camp cabins Phone # __1-705-325-2285
Financial Arrangements
Total cost per student: $ 370.00 Deposit required: $ 370.00 Payable to: Deer Park Public School
Excursion Staff
Teacher: Budd, Mann, Hockin, Seguinot, Downie, Gorczynski School contact during the excursion: 1-705-325-2285
Staff Supervisors:
Volunteer Supervisors (if known): ________________________________________________________________________________
Teacher Signature Date
Administrator Signature Date
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Form 511C
Aug. 30, 2004
Page 2 of 2
Please sign in either the YES or the NO box and return
this form to the teacher by:__APRIL 1ST, 2011
YES
I/we give permission for my/our child/ward, ___________________________________________________________, to participate
in the excursion
to ____________________________________________________________________on (date) _____________________________
Emergency Contact: Emergency Phone Number:
I/we give permission for my/our child/ward to be transported in a private vehicle (adult driver) ____, private vehicle
(student driver)____ who has been authorized by the principal.
Parent Signature ___________________________________________________________
Is there any change in medical information or a medical reason why your child should not participate in the activity, or which may
lead him/her to require special attention during the activity?
Should it become necessary for my/our child/ward to have medical care, I/we hereby give the teacher permission to use her/his best
judgment in obtaining the best of such service for my/our child/ward. I/we understand that any cost will be my/our responsibility. I/we
also understand that in the event of illness or accident, I/we will be notified as soon as possible.
Name of Parent/Guardian________________________________________________________________________
(printed name of parent/guardian)
Signature of Parent/Guardian Today’s date:
(or student, if 18 years old or older)
For students 18 years old or older, it is strongly recommended that the parent/guardian also sign this form.
I wish to volunteer on this trip: Yes______ No______
Signature of Parent/Guardian________________________________________________________ Today’s date:_____________
(or student, if 18 years old or older)
NO
I/we do not give permission for my/our child, _____________________________________________________________, to
participate in the excursion to ___________________________________________________________________________ on
(date)
Name of Parent/Guardian ________________________________________________________________________.
(printed name of parent/guardian)
Signature of Parent/Guardian Today’s date:
(or student, if 18 years old or older)
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Form 511C
Aug. 30, 2004
Page 3 of 2
Medical Information Form
The collection and retention of the information requested on this form is authorized and governed
by the Ontario Education Act and the Municipal Freedom of Information and Protection of Privacy Act.
The following information will be helpful to the teacher in making your child/ward comfortable and safe .
Student: ________________________________________________________________________Date of Birth: ________________________
Teacher: ___________________________________________________ Grade/Class: ________________
Parent/Guardian: _____________________________________________ Telephone: (H) ___________________ (B) ___________________
Ontario Health Number: _______________________ Family Doctor: ______________________________ Telephone: _________________
Medical Conditions
Please indicate any significant medical conditions, physical limitations, or any other concerns that might affect your child’s/ward’s full
participation in excursions/school activities.
Asthma Fainting Spells History of head injuries Rheumatic Fever
Chronic Nosebleed Feet or Leg problems Migraine Seizures
Diabetes Hemophilia/Bleeding disorders Rash Sleepwalking
Digestive upsets Heart problems Recent illness or operation Urinary infections
Ear, Nose, Throat infections Hernia Other ________________________
Dislocated shoulder; swollen, painful joints; ‘trick or lock’ knee or other joint disability
Give details of usual treatment for each of the above conditions indicated: ___________________________________________________
______________________________________________________________________________________________________________
Please explain if your child/ward has any medical condition that requires any modification of his/her program. ______________________
______________________________________________________________________________________________________________
Allergies/Asthma
Please list all known confirmed allergies to the following:
(a) Foods: _________________________________________________________________________________________________________
If foods are life-threatening, please explain the symptoms and the treatment: _________________________________________________
__________________________________________________________________________________________________________
(b) Medications: ____________________________________________________________________________________________________
(c) Other (e.g., bee or wasp stings, environmental allergies): __________________________________________________________________
Has your child/ward suffered any serious allergic or asthmatic reaction?
If so, please provide details, including the type and severity of reaction: _____________________________________________________
Is allergy considered: Mild____ Moderate____ Serious____ Life-Threatening____
Has a doctor prescribed an Epi-Pen for your child/ward? Yes____ No____
Has a doctor prescribed an inhaler for asthma? Yes____ No___ (Prescribed asthma inhalers must be carried by the student on the excursion.)
Has a doctor prescribed an inhaler for any other reason? Yes____ No____
Dietary Restrictions
Please list any foods your child/ward should not eat for medical, dietary, or religious reasons: _______________________________________
______________________________________________________________________________________________________________
Medication
Does your child/ward take prescribed medication on a regular basis? Please specify: _______________________________________________
What prescribed medication(s) should your child/ward have with him/her during the excursion? ______________________________________
General
(1) Does your child/ward wear or carry medical alert identification (e.g., bracelet)? Yes____ No____
If yes, please specify what is written on it: ____________________________________________________________________________
(2) Does your child/ward have any other relevant medical condition that will require modification of the program? Yes____ No____
If yes, please explain: ____________________________________________________________________________________________
(3) Does your child/ward have any special fears or conditions (e.g., anxiety, bed-wetting, nightmares), the knowledge of which will allow the teacher
to make the student’s excursion more relaxed? Yes____ No____ If yes, please explain:
Should it become necessary for my child/ward to have medical care, I hereby give the teacher permission to use her/his best judgment in obtaining
the best of such service for my child/ward. I also understand that in the event of such illness or accident, I will be notified as soon as possible.
Name of Parent/Guardian: _____________________________________________________________________(Please print)
Signature of Parent/Guardian: __________________________________________________________Date: _______________
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Form 511C
Aug. 30, 2004
Page 4 of 2
March 10, 2011
Dear Parents,
We are in the process of planning our annual end-of-year trip for our grade 7 students. The trip is a four night, 5 day trip to Camp
Wahanowin near Orillia. The camp offers a wide range of outdoor activities including water based activities. We strongly encourage
all our grade 7 students to participate, not only as a celebration of their grade 7 year, but also as an exercise in team building to prepare
them for their grade 8 year.
The trip will run from Monday, May 30 th to Friday, June 3rd. Our grade 7-8 qualifier Track and Field meet is also on May 30 th. We
will endeavor to work with students who wish to participate in this event and arrange alternative transportation on May 30 th.
Students will be housed in camp cabins, and will circulate in groups through a varied menu of well supervised activities, from archery
and basketball to arts and crafts, and also an aerial ropes course. If you would like further general information about the camp please
visit their website at www.wahanowin.com
The cost of the trip is $370. per student and everything is provided for at the camp. At this time we would ask that if your child is
interested in participating in this wonderful experience you complete the attached permission and medical form and return it to our
Main Office by Friday, April 1st. In addition, please also include a cheque payable to ‘Deer Park Public School’ for $370. Post-
dated cheques will be accepted but need to be dated no later than April 15th. If your family requires financial assistance to participate
in the trip please contact Mr. Howlett personally by phone.
Further communications will provide more detail as to packing lists, activity explanations, and exact travel details. We thank you
for your support in this venture. If you have any questions or comments please contact Mr. Howlett.
Sincerely,
Mike Howlett – Principal
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