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North Region

Cross Country

Booklet

October 2014

North Region

Cross Country Committee

Cross-Country Safety Guidelines attached.

Course Maps will be on separate email attachments.

No ‘hardcopies’ will be delivered.

Very Important Reminders

Washrooms: The Park has allowed us access to the washrooms provided they are used responsibly by the

students participating at the meets. We do not want to lose this privilege so let’s be vigilant about sending

adult supervisors at your school’s designated time as per the Washroom Schedule included in this package.

Parking: Parking is allowed only in the designated parking lots at Earle Bales. Emergency access routes

cannot be blocked. This year cars not parked in the parking lots will be towed at the owner’s expense.

Community Centre: The Community Centre is OUT of BOUNDS unless the days Master Convenor

determines that the weather conditions pose a safety risk to the students and adults. If the Community

Centre needs to be used all schools are responsible for any clean up that will be necessary to restore the

facility to pre-use conditions.

Clothing: Students must come prepared to the meets for all weather conditions!

Garbage in the Park: In our efforts to respect the environment, we ask all students, staff and spectators coming

to the cross-country meets to reduce, recycle and reuse. In addition to caring for our environment, we also need

to keep the parks clean so that we can continue to have permits granted for our meets. PLEASE SEND HOME REMINDERS ASKING PARENTS AND STUDENTS TO HELP US REDUCE THE

AMOUNT OF GARBAGE LEFT BEHIND IN THE PARK.

NORTH REGION CROSS-COUNTRY 2014

PLEASE REVIEW CAREFULLY

***********

********

1. Please make a copy of the booklet for your Principal.

2. Order your buses early. Volunteers please arrive on time.

3. Grades 3 and 4 walkthrough begins at 9:45 a.m. SHARP!!!

4. A) Please review Qualifying Procedures from Divisional and Regional Meets.

B) Same Sticker Procedures for “Qualifying Teams” from the Divisional

Meets as last year.

5. Review ORDER OF EVENTS. See inside booklet for details.

6. If extra stickers are required, they are AVERY FILE LABELS 5160. Some

extras will be available on your race day.

7. A washroom supervision schedule will be used.

8. Keep all permission and media consent forms on file at your school.

9. The convenors strongly recommend that athletes should compete only at their

age appropriate level. Runners should not race against older runners,

especially at a longer distance.

10. Safety is the convenor’s first and foremost concern, therefore:

a) The services of a Professional Athletic Therapy Association will be

available to service the needs of the athletes and coaches. All

SERIOUS injuries should be reported to the race officials for

treatment. Bring your own First Aid kits for minor scrapes.

b) Proper environmental precautions must be taken (cold, wet, hot, sunny

weather must be prepared for).

c) Runners with inhalers and/or epipens must keep their

inhalers/epipens with them at all times, especially while running.

d) It is very important that coaches supervise their students throughout the

day but especially immediately after a race. All runners must be

accounted for after each race. Any runner returning to his/her

coach with a sticker still on, after a race, must report to the

scorer’s table. 11. Please refer to the Excursion Manual for proper supervision ratios.

12. Please refer to the Ontario Interschool Safety Guideline for information and

sample permission forms.

13. Runners must have a minimum of 20 training days prior to their first meet.

***Daily results will be available outside of the entrance office.

Coaches are responsible for getting these BEFORE their next meet. Results will be emailed to the schools in the evening. ***

NORTH REGION ATHLETIC ASSOCIATION

On behalf of the North Region Athletic Association, we would like to

extend our thanks to:

Master Convenors: Shawna Campbell, Principal St Wilfrid

Lucia Graziano, Teacher St Robert

Michael Sullivan, Retired Teacher

And the rest of the cross country volunteers for their hard

work and cooperation in participating in this year’s Cross-

Country Meets.

Thank you to:

Rob Kelly

and

Nelli Domingues

For permits and operational logistics

NORTH REGION CROSS-COUNTRY 2014

SCHEDULE OF EVENTS

“DIVISIONAL EVENTS” EARL BALES PARK

Tuesday October 14th Meet 1

Wednesday October 15th Meet 2

Thursday October 16th Meet 3

“REGIONAL EVENT” EARL BALES PARK

Tuesday October 21st Regionals

CITY FINALS EARL BALES PARK

Tuesday October 28th City Final

The City Cross-Country Championships will be hosted by

The North Region Athletic Association

At Earl Bales Park in North York.

All meets will be run even if there is a slight rain.

Please be prepared for these conditions.

NORTH REGION CROSS COUNTRY

DIVISIONS

2014

Earl Bales Park

2014-2015

NORTH REGION

CROSS-COUNTRY GROUPINGS

FINAL DATES

Divisionals: October 14, 2014 Regional: October 21, 2014

October 15, 2014

October 16, 2014

City: October 28, 2014

Locations: Earl Bales (divisional & Regional)

Earl Bales (city)

MEET 1

OCTOBER 14

MEET 2

OCTOBER 15

MEET 3

OCTOBER 16

Blessed Sacrament St. Robert St. Bonaventure

Regina Mundi St. Cyril St. Fidelis

St. Monica St. Edward St. Augustine

St. Conrad St. Agnes Our Lady of Wisdom

St. Gabriel St. Norbert St. Charles Borromeo

St. Thomas Aquinas St. Kevin St. Raphael

Saint Kateri Blessed Trinity Sts. Cosmas & Damian

St. Gerald St. Jerome St. Timothy

St. Paschal Baylon Precious Blood St. Wilfrid

St. Antoine Daniel D’Arcy McGee Msgr. Charbonnel

Blessed Margherita St. Jane Frances Our Lady of Assumption

St. Matthias St. Charles Garnier St. Matthew

Immaculate Conception St. Margaret Holy Redeemer

St. Francis Xavier St. Francis de Sales Our Lady of Guadaloupe

St. Martha

*****Reminder******

AGE, DIVISIONS, DISTANCE AND ORDER OF RACES

Note: EACH SCHOOL ALLOWED ONLY 8 RUNNERS PER RACE.

***

Grade 8 BOYS 3000m 2001 (or earlier)

Grade 8 GIRLS 2500m 2001(or earlier)

Grade 7 BOYS 2500m 2002

Grade 4 GIRLS 1500m 2005


Grade 3 GIRLS 1500m 2006 (or later)

Grade 3 BOYS 1500m 2006 (or later)






Remember there is an age restriction to every race.

This age is your athlete’s age as of January 1, 2014.

In determining which category to enter your students, use only the year

indicated in the far right column. It will eliminate a great deal of confusion.

ATTIRE:

All participants should be properly equipped with shorts, (or track pants if inclement

weather), running shoes, a school T-shirt or jersey. Cover-ups, sunscreen, hats, and

extra water are also recommended. Extra running shoes and socks are suggested.

NO SOCCER SHOES OR SHOES WITH SPIKES (CLEATS) ARE

ALLOWED.

Students wearing said equipment will be disqualified!

Each competitor will also be required to wear an identification sticker with the

specifications on it that are outlined later in the booklet.

RUNNER’S BEHAVIOUR

Runners whom officials judge to have conducted themselves in a very

unsportsmanlike manner: deliberate pushing, tripping, using foul language, not

following course markings, obstructing competitors when being overtaken, WILL BE

DISQUALIFIED. Adult Course Marshalls can pull a runner who is in obvious

physical discomfort.

IMPORTANT: For safety concerns, students are not permitted to run with any type

of listening device i.e., Ipod, MP3, etc.

SPECTATORS, COACHES, PARENTS AND OTHERS….

Spectators and parents should not be on the course or interfere with the runners for

any reason. The individual(s) interfering may cause their school (team) to be

penalized. Any injuries or emergencies will be addressed by the organizing

committee. Students are not permitted to bring footballs, softballs, soccer balls,

ipods, listening devices or radios to any meet.

RESULTS Please Read Carefully

Results will be available at the conclusion of each race by the entrance office.

Coaches are responsible for writing the names of the qualifiers from their

particular school. No summary booklets will be available on race day. Results will

be emailed to the schools.

GARBAGE

Each school is to bring TWO large garbage bags for their use.

MAPS OF COURSE

The maps for the various courses are enclosed with the package that will be sent soon.

It is important that you familiarize your team with the course before the race begins,

specifically during the walk through.

DISQUALIFICATIONS Running off the course.

All runners are expected to run the course as outlined on the maps of the courses.

Any runner who runs a different route will be subject to disqualification by the course

marshals.

FIRST AID KIT, LUNCHES, WEATHER PROTECTION Because there are few picnic tables available, teams are asked to sit on the grass. Schools are urged to

bring A FIRST AID KIT, BLANKETS, PLASTIC SHEETS, UMBRELLAS, GARBAGE BAGS

ETC. for their convenience.

CANCELLATION AND RAINDATE

The only reason that the meet will be cancelled is due to very inclement weather, a

message will be sent on EMAIL from Nelli Domingues, Resource Teacher to the

principal, secretary and the athletic rep. of your school by 8:00 a.m. Schools are

asked to check these sources and not the SBSSS/North office. Convenors will notify

schools later in the day regarding a rain date.

OFFICIALS

Each school must provide officials at their DIVISIONAL MEET. They will be

assigned a role and should meet with the HEAD CONVENOR no later than 9:15

a.m. on the day of the meet. If someone cannot attend their scheduled job they

are responsible for finding a suitable replacement.

WASHROOM SUPERVISION

A washroom supervision schedule has been very effective in the past. A schedule is

enclosed within this booklet. Please refer to the schedule for your assigned time.

Supervision will be for approximately 15 minutes at a time. Please have a school

designate available.

STUDENT BEHAVIOUR

In the past, behaviour at the North Region meets has been very good. It is hoped that

this standard will be maintained through the careful supervision by all coaches. It is

especially important that the finish line area be kept clear of students, parents and

coaches to facilitate scoring. Any questions or concerns regarding results or scoring at

the finish line or scoring table should be addressed by coaches, not parents and

directed to the meet directors to address. Please try to limit the number of students

using the washroom facilities at any one time to avoid loitering.

For further information, please EMAIL

Shawna Campbell, Lucia Graziano

Or

Mike Sullivan

IMPORTANT INFORMATION FOR COACHES TO NOTE

NAME TAGS: DO NOT PIN! PLEASE KEEP DRY!

PUT ON RUNNER JUST BEFORE THEIR RACE.

A) DIVISIONAL MEETS:

Name tags have been provided with the school name, 3 letter computer codes,

the age and sex of the runner as well as the distance. Coaches need to add the

runner’s name (print clearly) above the school name with a waterproof pen.

Each participant will need only one WHITE tag for their race; ONLY USE

WHITE TAGS supplied by the Physical Education Department. Please keep

them dry.

B) REGIONAL FINAL:

The coach of those advancing to the North Region Meet will have to pick up

their completed stickers from the meet convenor the morning of the meet. The

stickers will be completely filled in identifying name, age and race. Please

check that these stickers are accurate.

Sample: Use only waterproof ink to mark labels (markers run).

John Smith

Holy Runners-HRN

Grade 4 Boy

1500m

C) HELPFUL HINT:

For your convenience, affix a colour-coded mark to the bottom right corner of

each participant’s nametag so that they will be easily visible on the scoring

table.

Please read revised “ADVANCING TEAM” sticker procedures on next

pages!!!

SCORING FOR ‘DIVISIONAL’ MEETS, & ADVANCEMENT

(October 14, 15, 16)

1 Coaches are responsible on the day of their meet for noting all their own team

and individual qualifiers who will be advancing to the next meet. Results will

be posted at the Ticket Chalet.

2 Each race is scored in the following manner at the DIVISIONAL level:

1st place = 60 points, 2nd place = 59 points, 3rd place = 58 points, etc…

The winning school at the end of the day is the school that accumulates the

highest total points

The runners must be able to finish their designated distance during practices

without walking.

It is not necessary to enter the maximum 8 runners as only the top 3 runners

in each race from each school score points.

3 Awards: See Award Structure Page

4 Schools with three or more runners in a race are eligible for team awards and

advancement. See: Qualifiers From Divisional & Regional Meets Page.

a) The first three runners from each team will count towards a team

score and;

b) The first three runners from each of the two teams with the highest

point totals will advance as a team to the Regional Finals, no matter

where they finish in the race.

c) A 4th, 5th, 6th, 7th, 8th, 9th, or 10th Team Runner qualifies ONLY if that

runner finishes in the TOP 22.

d) All runners will wear white stickers only. The top two teams from

divisional and regional meets win a champion and finalist pennant

respectively and advance as to the next meet. However, they will still

wear white stickers. At the regional and City meets all schools are

now eligible to win a team pennant. A third runner on the top two

winning teams who finishes outside the first 22 runners still advances

to the next meet. See Sample on Qualifiers page.

5 Individuals will still advance to the Regional Finals if they are among the top

22 runners.

6 ONE Divisional school champion will be determined for each day by adding

the scores of the top three runners from each school for each of the twelve

races. Highest score wins.

Checklist for coaches: A Kleenex, UMBRELLAS, cell phone if possible

B Permission forms on file at the school

C Supervisors (TCSB policy 1:10)

D Bus list for school office

E First Aid Kit

F Stopwatch, clipboard, pens, markers

G Blankets, cover-ups, sunscreen, water

SCORING AT REGIONAL FINAL MEET, & ADVANCEMENT

(October 21st)

1 Coaches are responsible on the day of their meet for noting all their

own team and individual qualifiers who will be advancing to the City

Meet.

2 Each race is scored in the following manner at the REGIONAL level:

1st place = 60 points, 2nd place = 59 points, 3rd place = 58 points, etc..

3 Awards: See Award Structure Page

4 The TOP 2 teams win a champion and finalist pennant respectively.

A The first three runners from each team will count towards a

team score; B The first three runners from each of the two teams with the

highest point totals will advance to CITY finals, no matter

where they finish in the race.

C A 4th, 5th, 6th, etc. team runner qualifies ONLY if that runner

finishes in the TOP 22 finishers.

5 Individuals will still advance to the City Finals if they are among the

top 22 runners.

6 The Regional Champion and Finalist Awards are determined by adding

the scores of all entered athletes from each school in all races. Highest

Total Wins.

7 Information about the CITY FINALS will be distributed to all schools

from the NORTH REGION ATHLETIC ASSOCIATION following

Regionals.

NORTH REGIONAL FINALS

Tuesday, October 21st, 2014 at EARL BALES PARK

1 ORDER OF EVENTS:

The order of events will be the same as the order of races at the three

Divisional Meets.

2 ENTRIES: From each Divisional Championship, the SAME format was used to

qualify runners for North Regional Meet. The number of teams and

individuals to qualify will be the same from all Divisional Meets. A

team consists of a minimum 3 runners, a maximum of 8.

*****PLEASE REVIEW QUALIFYING PROCEDURES CAREFULLY*****

AWARDS

***

I) DIVISIONALS

a) There will be a PENNANT awarded to the Championship school team in all

three meets.

b) There will be a PENNANT awarded to the Finalist school team in all three

meets.

c) There will be MEDALS awarded to the 1st, 2nd, and 3rd place winners in each

race.

d) There will be numbered RIBBONS for 4th through 10th place.

e) There will be PARTICIPANT RIBBONS for 11th place on that will be handed

out either in the chute as the runners finish or in bundles at the announcer’s

table.

f) There will be up to 8 TEAM RIBBONS for the winning team of each race.

II) REGIONAL FINALS

a) A PLAQUE will be presented to the overall winning school.

b) PENNANTS will be awarded to the first, second and third place schools.

c) MEDALS will be awarded to the top 3 finishers in each race.

d) RIBBONS will be awarded to 4th to 10th place finishers in each race.

e) A PENNANT and 4 RIBBONS will be awarded to the winning team in each

race.

Qualifiers From Divisional & Regional Meets

1 Only the first 22 finishers in each race will advance to the next meet. This

includes all members of the TOP TWO Qualifying Teams.

2 An advancing team MUST consist of a minimum of THREE runners up to

a maximum of 8 from a DIVISIONAL Meet, and FOUR from the Regional

Meet.

3 Therefore, if an advancing team’s 3rd qualifying runner finishes after the first

22 runners (i.e. 23rd, 24th, 25th, etc), that third team runner WILL ADVANCE

to the next meet. (See Example Below).

4 However, a 4th, 5th, 6th, 7th, or 8th qualifying team runner must finish in the top

22 finishers in order to advance. There are no exceptions.

NOTE: a) Only the TOP 3 runners on a team are used for scoring

purposes;

b) Where 2 TEAMS are tied for qualifying to the next meet, the

position of the highest placed team runner will be used to break

the tie.

SAMPLE RACE SCORING SUMMARY: DIVISIONAL AND REGIONAL

NOTE: a) 1st=60 points, 2nd=59 points, 3rd=58 points, 4th=57 points, etc.

b) All team scores have been totalled.

1 Q 12 Q 23 T-2 (DNQ) 34 DNQ

2 T-1 13 Q 24 T-1* 35 DNQ

3 T-2 14 Q 25 DNQ 36 DNQ

4 Q 15 Q 26 DNQ 37 DNQ

5 T-1 16 Q 27 DNQ 38 DNQ

6 Q 17 Q 28 T-1 (DNQ) 39 DNQ

7 Q 18 Q 29 DNQ 40 DNQ

8 Q 19 T-2 30 T-1 (DNQ) 41 DNQ

9 Q 20 T-2 31 DNQ 42 DNQ

10 T-2 21 T-2 32 DNQ 43 DNQ

11 Q 22 T-2 33 DNQ 44 DNQ

From this race scenario:

a) T-1 totalled 152 points and T-2 totalled 151 points (from the top 3 team

finishers).

b) Three of T-1’s team advance (minimum required), even though the third best

finisher was 24th*.

c) All SIX of T-2’s team advance because all six placed in the first 22 finishers.

d) In this particular case a total of 23 runners will advance to the next meet

instead of the usual 22.

WASHROOM SCHEDULE Divisionals

Please make sure your school’s volunteer is on time. Thanks.

TIME Meet #1

October 14th

Meet #2

October 15th

Meet #3

October 16th

9:40 Blessed Sacrament St. Robert St. Bonaventure

10:00 Regina Mundi St. Cyril St. Fidelis

10:20 St. Monica St. Edward St. Augustine

10:40 St. Conrad St. Agnes Our Lady of Wisdom

11:00 St. Gabriel St. Norbert St. Charles Borromeo

11:20 St. Thomas Aquinas St. Kevin St. Raphael

11:40 Saint Kateri Blessed Trinity Sts. Cosmas & Damian

12:00 St. Gerald St. Jerome St. Timothy

12:20 St. Paschal Baylon Precious Blood St. Wilfrid

12:40 St. Antoine Daniel D’Arcy McGee Msgr. Charbonnel

1:00 Blessed Margherita St. Jane Frances Our Lady of

Assumption

1:20 St. Matthias St. Charles Garnier St. Matthew

1:40 Immaculate Conception St. Margaret Holy Redeemer

2:00 St. Francis Xavier St. Francis de Sales Our Lady of

Guadaloupe

2:20 St. Martha

2:40

Washroom Schedule

North Regional Finals

Tuesday, October 21st, 2014

9:40 Blessed Sacrament St. Robert St. Bonaventure

10:00 Regina Mundi St. Cyril St. Fidelis

10:20 St. Monica St. Edward St. Augustine

10:40 St. Conrad St. Agnes Our Lady of Wisdom

11:00 St. Gabriel St. Norbert St. Charles Borromeo

11:20 St. Thomas Aquinas St. Kevin St. Raphael

11:40 Saint Kateri Blessed Trinity Sts. Cosmas & Damian

12:00 St. Gerald St. Jerome St. Timothy

12:20 St. Paschal Baylon Precious Blood St. Wilfrid

12:40 St. Antoine Daniel D’Arcy McGee Msgr. Charbonnel

1:00 Blessed Margherita St. Jane Frances Our Lady of

Assumption

1:20 St. Matthias St. Charles Garnier St. Matthew

1:40 Immaculate Conception St. Margaret Holy Redeemer

2:00 St. Francis Xavier St. Francis de Sales Our Lady of

Guadaloupe

2:20 St. Martha

Coaches:

The following is an APPROXIMATE timeline for races that you may wish to share

with parents, etc.

Please ensure they are aware that depending upon conditions, etc. races could take

place earlier or later than these approximate times.

10:30 Grade 8 Race 1 3000m Boys

10:45 Grade 8 Race 2 2500m Girls







12:30 Grade5 Race 9 2000m Boys




Sample

Cross-Country Running Parent/Guardian Information Form

Dear Parent/Guardian:

Your son/daughter has expressed an interest in trying out for the school’s cross-country running

team. Please review the information below and complete the permission form as indicated.

Cross-country running takes place outside so parents/guardians should ensure their

son/daughter is dressed appropriately for the weather conditions they may encounter. Your

son/daughter should have proper sun protection and an adequate supply of food and fluids for

the meet day.

The practices are scheduled for the following:

Day Time Location

The Cross-Country Meets are scheduled as follows:

Date Time Location Type of Meet

Invitational Meet

Divisional Meet

Regional

City

At times practices and/or meets take place off the school property. The following

transportation arrangements may be used:

walking, school bus, volunteer drivers, public transportation,

taxis

Please retain the “Cross-Country Running Parent/Guardian Information Form”. Please

complete and return to the school a signed copy of the “Cross-Country Running

Parent/Guardian Permission Form”.

ELEMENTS OF RISK NOTICE Within the Toronto Catholic District School Board the safety and well being of students is a prime concern. However the risk of injury exists in every physical activity. Due to the very nature of cross-country running there is always a risk of injury. Every attempt will be made to manage, as effectively as possible, the foreseeable risks involved for students while participating in cross-country running.

Sample

Cross-Country Running Parent/Guardian Permission Form

Name of Son/Daughter: ____________________________ Grade: _______________________

Emergency Contact No.: _________________________Health Card No: _________________

The practices are scheduled for the following:

Day Time Location

The Cross-Country Meets are scheduled as follows:

Date Time Location Type of Meet

Invitational Meet

Divisional Meet

Regional

City

At times practices and/or meets take place off the school property. The following

transportation arrangements may be used:

walking, school bus, volunteer drivers, public transportation,

taxis

Medical Information

I have completed and submitted the Physical Activity Medical Information Form

Yes No

If no, please contact the school to obtain a copy of this form. It is important that this form be

completed and returned to the school prior to your son/daughter taking part in cross-country

running.

I give permission for my son/daughter ____________________________________, to take

part in all aspects of the cross-country running activities. In signing this form, I acknowledge the

element of risk information noted on the information page.

_________________________________ ____________________________________

Date Parent/Guardian Signature

Sample PHYSICAL ACTIVITY MEDICAL INFORMATION FORM

Dear Parent/Guardian:

Vigorous physical activity is essential for normal, healthy growth and development. Growing bones and

muscles require not only good nutrition, but also the stimulation of vigorous physical activity to increase

the strength and skills necessary for a physically active lifestyle. Active participation provides

opportunities for students to discover and trust themselves and gain the confidence necessary to play

and work cooperatively and competitively with their peers. Physical education activities at both the

curricular and co-curricular level provide opportunities for students to experience the benefits of physical

fitness, understand and make decisions regarding personal fitness and learn the value of physical

activity in their daily lives.

It is important that your child participate safely and comfortably in the physical education program. In

your child’s best interests we recommend the following:

a) An annual medical examination.

b) Appropriate attire for safe participation (T-shirt, shorts or track pants and running shoes). Hanging

jewellery must not be worn. Jewellery which cannot be removed and which presents a safety

concern must be taped.

c) The wearing of an eyeglass band and/or shatterproof lens if your child wears glasses which cannot

be removed during physical education classes.

d) The wearing of sun protection for all outdoor activities.

e) Safety inspection at home of any equipment brought to school for personal use in class, e.g. skis,

skates, helmets etc.

Please complete the medical information form attached and have your child return it to his/her teacher.

If you require further information, please contact the school

ELEMENTS OF RISK NOTICE Within the Toronto Catholic District School Board the safety and well-being of students is a prime concern. However the risk of injury exists in every physical activity. Due to the very nature of some activities, the risk of injury may increase. Every attempt is made to manage, as effectively as possible, the foreseeable risks involved for students while participating in school physical activities.

Sample

PHYSICAL ACTIVITY MEDICAL INFORMATION FORM Name of Student: ___________________________________

Grade:________________

School: _____________________________

Teacher_____________________________

I would like to inform the school about these facts pertaining to my child’s

physical/medical condition related to his/her participation in Physical

Education Curricular and Intramural Programs.

1. Please indicate if your son/daughter/ward has been subject to any of the

following and provide pertinent details:

epilepsy:

______________________________________________________________

diabetes:

______________________________________________________________

__

orthopaedic problems

_______________________________________________________

heart disorders:

___________________________________________________________

asthma:

______________________________________________________________

a medical inhaler (puffer) is required

allergies:

______________________________________________________________

an Epi-Pen© is required

head or back conditions or injuries (in the past two years):

______________________________________________________________

______________________________________________

arthritis or rheumatism:

____________________________________________________

chronic nosebleeds:

_______________________________________________________

dizziness:

______________________________________________________________

fainting:

______________________________________________________________

___

headaches:

______________________________________________________________

dislocated shoulder:

_______________________________________________________

hernia; swollen:

___________________________________________________________

hypermobile or painful joints:

________________________________________________

trick or lock knee:

_________________________________________________________

2. What medication(s) should the participant have on hand during the physical

activity?

______________________________________________________________

______________________________________________________________

________________________

3. Please complete the following if applicable:

A) My son/daughter/ward wears:

eyeglasses

contact lenses

B) My son/daughter/ward wears:

a medical alert bracelet

neck chain

carries a medical alert card

Please specify what is written on it:

______________________________________________________________

______________________________________________________________

________________________

4. Please indicate any other relevant medical condition that will require

modification of the program:

______________________________________________________________

______________________________________________________________

________________________

In signing this form, I acknowledge the element of risk information noted above. Parent/Guardian Signature:

____________________________________________________

Date: ___________________________________________

PLEASE NOTE: FREEDOM OF INFORMATION

The information on this form is collected under the authority of the Education

Act, R.S.O. 1991, Section170(1).This information is protected under the

Freedom of Information and Protection of Privacy Act and will be utilized only

for the purposes related to the Board’s Policy on Risk Management. Any

questions with respect to this information should be directed to your school

principal.

MEDICAL SERVICES AUTHORIZATION (Optional) In case of emergency medical or hospital services being required by the above listed participant, and with the understanding that every reasonable effort will be made by the school/hospital to contact me, my signature below authorizes medical personnel and/or hospital to administer medical and/or surgical services including anesthesia and drugs. I understand that any cost will be my responsibility. __________________________________________ __________________________ Signature of Parent/Guardian Date

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