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
Statement of Participation
Number of class periods/ to be absent
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:
Part C: Completed by Parent/Guardian
Student’s full name
Student’s full address
Home phone number
Mother’s maiden name
Student’s medicare number
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
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
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.