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Phs extra curricular authorization form - track and field
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Phs extra curricular authorization form - track and field

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  • 1. Pontiac High School Extra-Curricular Activity Authorization Part A: Completed by Teacher Supervisor(s):MacIntosh, Lottes, Cobus, Rietveld Description of Activity Event Track & Field Regionals Place of Event Ecole Secondaire Mont-Bleu, Gatineau Date of Event Friday May 23, 2014 3:15-5 pm Practices MONDAY & WEDNESDAY UNTIL THEN Departure Time/Place 7:30 a.m. PHS Return Time ~5 pm PHS Cost of Event Registration is $30 – but if you are a member of the X-Country Team, you are already registered. Registration Deadline May 1, 2014 Preparation Wear appropriate clothes, food/water for event. Part B: Completed by Student Schedule of Classes Missed Period/Day 1st 2nd 3rd 1 2 3 4 Statement of Participation Number of class periods/ to be absent Periods Days I understand that it is my responsibility to find out what work or assignments were covered during my absence, and that I must undertake to complete the work. Student signature: Date:
  • 2. Part C: Completed by Parent/Guardian Student’s full name (print clearly) Student’s full address Student’s birthdate Home phone number Mother’s name Mother’s maiden name Phone number Father’s name Phone number Student’s medicare number Expiry date Family doctor Phone number Medical problems: (allergies/respiratory issues/skin sensitivities, etc) 1. I hereby give my child _____________________________________________ permission to take part in the activity described in part A. 2. I hereby appoint any or all of the trip supervisors to act as my agent in my name to engage such medical and hospital care as may be required. 3. I hereby accept financial responsibility for any willful damage caused by my child. 4. I give the trip supervisor(s) permission to send my child home by public transportation at any time as a result of inappropriate behaviour. I will accept the financial cost of such public transportation. 5. I understand that all school rules and regulations apply during this trip. This includes the Drug and Alcohol Policy which includes a two week suspension for any infringement. 6. I acknowledge that I have read and fully understand this authorization and that my child will not be allowed to participate unless this form is completely filled out, including the timetable on the reverse side. Signature of parent/guardian Date Education is our prime mission at PHS. You, the parent/guardian and your child must determine where or not your child can afford the time from classes for this activity.

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