JOHN OLIVER SECONDARY SCHOOL

JO Digital Immersion Mini School Student Commitment & Parent/Guardian Field Studies Consent Form
530 East 41st Avenue, Vancouver, BC V5W 1P3
Telephone: 604.713.8938

Teacher/Organizer of Activity:_MS. T.LAUMEN, MR.I.LAU, MR. P.LEE, MR. T.HOFFMANN_________________________________

To the Parent(s)/Guardian(s) of: ____________________________Student #: ____________________ Grade/Division: ________
The purpose of this form is to provide notice of a field studies activity involving your child, and to seek your support and permission for your child to
participate. Field studies activities provide students with valuable learning experiences beyond the classroom. Participation in these activities that involve
time away from the classroom also requires the student to be responsible enough to meet their commitments to the class time that is missed.
This is an important document. Please review its contents carefully prior to providing permission for your child to participate in this excursion.
Clarify any questions or concerns with the Lead Teacher BEFORE signing it.
If this form is not signed & returned to the school by SEPT.16, 2022_, your child MAY BE PREVENTED FROM PARTICIPATION.
PROGRAM/ACTIVITY INFORMATION (to be completed by Educator in Charge)
ACTIVITY:JO MINI SCHOOL FALL TRIP TO VICTORIA, BC DATE(S)&TIME(S): OCT.3-5 (GR.8,9,10)/OCT.5-7 (GR.11,12) 2022_
DETAILS OF ACTIVITIES TO BE UNDERTAKEN: _WALKING TOUR(S)/RESEARCH/OBSERVATION/ANALYSIS ____
PURPOSE OR EDUCATIONAL GOAL(S): CURRICULUM ENRICHMENT – GEOGRAPHY/URBAN STUDIES/HISTORY/ECONOMICS
ITINERARY/ACTIVITIES: __SEE ATTACHED ITINERARY___________________________________________________________ _
METHOD OF TRANSPORTATION (IF APPLICABLE): _ FERRY/CHARTER BUS BY:_BC FERRIES/WILSON’S
EDUCATOR-in-CHARGE: MS.T.LAUMEN ADDITIONAL TRIP SUPERVISORS:MR.I.LAU, MR.P.LEE,MR.T.HOFFMANN
COST TO THE STUDENT: $_300__ WHAT TO BRING: ___SEE ATTACHED LISTS_____________________________________
BEHAVIOUR EXPECTATIONS: All VSB & school rules are in effect during extracurricular activities.
SCHOOL RESPONSIBILITIES
The school will make every reasonable effort to ensure or ascertain that:
a) The staff, volunteers and/or service providers involved are suitably trained and qualified; b) the students are adequately supervised over all
aspects of the program/activity; c) the location(s) used are appropriate and safe for the activity(ies) and group; d) a Safety Plan is in place to
identify and manage known potential risks; e) an Emergency Plan is in place to deal with an injury or illness to any of the students.

POTENTIAL KNOWN RISKS AND SPECIAL SAFETY INFORMATION

The purpose of this section is to detail and reinforce all potential known risks of participation in the field study to ensure parents/guardians are providing
informed consent. Safety issues and precautions discussed with students should also be referred to - for example, if the students will be required to wear
any specific safety equipment, such as goggles or helmets. Some service provisions may be subject to requirements reflecting current health guidelines
that may require documentation.
Additional Comments/Requirements:

TEACHER NOTIFICATION/ACKNOWLEDGMENT
(signifies that teachers have been given notice of absence from their class for the specified activity)
PERIOD 1 TEACHER:
PERIOD 2 TEACHER:
PERIOD 3 TEACHER:
PERIOD 4 TEACHER:

PARENT/GUARDIAN CONSENT & ACKNOWLEDGEMENT OF RISK, EXPECTATIONS & STUDENT RESPONSIBILITY

Activity/Event: _JO MINI SCHOOL FALL TRIP TO VICTORIA, BC Dates & Times: __ OCT.3-5 (GR.8,9,10)/OCT.5-7 (GR.11,12) 2022____
While school staff will take reasonable steps to prevent injuries to students, some degree of risk is inherent in the nature of this activity, and
may occur without fault on the part of the student, school board, its employees or agents, or the facility where the activity is taking place.
By allowing your child to participate in this activity, you are agreeing that the activity described above is suitable for your child, and that
there is a risk of injury associated with the activity.

➢ My child has been informed that they are to abide by the rules and regulations, including directions and instructions from the
school’s and/or service provider’s administrators, instructors, and supervisors over all phases of the program/activity.
➢ In the event my child fails to abide by these rules and regulations, disciplinary action may require their exclusion from further
participation or that I be contacted to have them picked up, unless I have specified other transport arrangements.
➢ I acknowledge that the trip supervisors may secure transport to emergency medical services as they deem necessary for my child's
immediate health and safety, and that I may be financially responsible for such services.
➢ I acknowledge and accept that due to this activity requiring the student to be absent from class, that the responsibility lies with the
student to make the necessary arrangements to meet their commitments to their school subject classes, and that failure to do so
may result in lost credit and/or ineligibility to participate in subsequent activities.
➢ I acknowledge and accept that my child will have the opportunity to select their preference for the overnight rooming arrangement
in relation to gender (all female, all male, all gender inclusive).

I, _________________________ (name of parent/guardian) give permission for ______________ _____ (name of student) to participate in the
activity described above, and understand and accept the conditions, expectations and responsibilities as outlined above.
Date: ________________ Name of Parent/Guardian (Please print): ___________________________ Signature: ____________________________
Date: ________________ Name of Student (Please print): __________________________________ Signature: ____________________________
Parent/Guardian Contact Numbers: Day _____________________ Evening ______________________ Cell _________________________
Comments (please include any restrictions or limitations which would prevent your child from fully participating in this trip, or any other special concerns
which Board staff should be aware of surrounding your child._______________________________________________________________________
NOTE: Efforts to minimize costs have been made to support student participation.In accordance with VSB policy Students Fees, Fines& Hardship no
student shall be denied opportunity to participate because of financial inability Please contact the Teacher if you have questions or need assistance.
Administrator: Mr. B. Schieman
2022 JODIMS Field Studies Consent Form JO TemplateRevised 2022SEP
 JOHN OLIVER SECONDARY SCHOOL
Medical Information For Extracurricular Participation
The collection and retention of information requested on this form is authorized and governed by
the British Columbia School Act and the Freedom of Information and Protection of Privacy Act.

OFF-SITE EXPERIENCE EMERGENCY MEDICAL INFORMATION

The following information will be helpful to the teacher in making your child’s field studies experience comfortable, safe and pleasant.
(Please print carefully and legibly)

Student Name: _________________________________ Birth Date: ______________________ Email:_________________________

Grade:_________ Student # __________________________________ Teacher:_____ _______________________________

Address: ____________________________________________________________________________________________________

BC Medical Services Plan Personal Health No.: ______________________ Student School Accident Insurance:  Yes  No

Allergies (e.g., specific drugs, certain foods, insect stings, hay fever) Specify:

__________________________________________________________________________________________________________

Reaction(s) to above? ________________________________________________________________________________________

Carries Epi pen?  Yes  No Inhaler?  Yes  No Medical Alert Bracelet?  Yes  No

Date of last Tetanus shot: __________________________

Medical/physical conditions that may affect participation in the stated program/activity (e.g., recent illness or injury, recent hospitalization or
surgery, chronic conditions, phobias, etc.). Be specific:

__________________________________________________________________________________________________________

Specify the condition(s) and requirements for program modification or specific activities your child should not participate in:

__________________________________________________________________________________________________________

Prescribed medication(s) taken at this time (name, reason, dosage, storage, potential side effects/treatment of such):

__________________________________________________________________________________________________________

Other Health/Medical/Dietary Concerns/restrictions:

__________________________________________________________________________________________________________

Emergency Contacts:
1) ____________________________________ Phone: (H) __________________ (W) ________________ (C) ________________

2) ____________________________________ Phone: (H) __________________ (W) ________________ (C) ________________

Name of Physician ____________________________________________________________ Phone # ______________________

ACKNOWLEDGEMENT OF CONSENT

Parent/Guardian who is filling out and signing this form:______________________________________________________________

Should it become necessary for my child to have medical care, I hereby give the teacher permission to use his/her best judgment in
obtaining the best of such service for my child. I understand that any cost will be my responsibility. I also understand that in the event of
illness or accident, I will be notified as soon as possible via the emergency contact information listed above.

Name (please print) _________________________________________ Signature ________________________________________

2022 JODIMS Field Studies Consent Form JO TemplateRevised 2022SEP