2015 Waiver Form

Walton After School Activity Waiver and Behaviour Policy Form
2015/2016 School Year

A waiver form must be completed for each child each school year (September to June).
This waiver form is for the 2015/2016 school year.

Child Information

* Indicates required field

Child Name *

First

Last

Grade *

Division *

School *

Birthdate *

Child's Doctor *

Doctor Phone Number *

Child's Medical Number *

Medical Concerns (allergies, medications, restrictions, injuries...) *

Guardian Information

Guardian Name *

First

Last

Address *

Guardian Email *

Guardian Phone Number *

Phone Type *

Alternate Phone Number *

Alternate Phone Type *

Dismissal Procedure

How will Child get home *

Child will be picked up Child will walk home

If Child to be picked up, who will pick up (name, relation) *

Waiver

-I/We agree that our child(ren) will follow all reasonable directions and instructions given by the Program Instructor(s) in connection with the operation of any and all after school Programs offered at Walton Elementary School.

-I/We release and forever discharge School District #43, school staff and program Instructors of and from all manner of actions,claims and demands of whatever nature which result from any accidental injury, loss of expense sustained, arising out of or in any way connected with participation in any After School School program, service or event.

-In the event that our child(ren) is/are injured, ill or in need of immediate medical attention and I/we are unable to be contacted,I/we authorize school staff, Program Instructors and volunteers to seek medical attention on my/our behalf.

-I/We understand that our child(ren) may be photographed while participating in Walton After School programs and authorize Walton Elementary or Walton PAC to use, at their discretion, any photographs containing our child(ren)’s images taken while participating in Walton After School Programs for the Walton or Walton PAC newsletter.

-While Walton Elementary will take reasonable steps to prevent injuries to students, some degree of risk is inherent in the nature of the activities, 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 my/our child to participate in this activity, I/we are agreeing that the activity described above is suitable for my/our child, and that there is a risk of injury associated with the activity.

**Running Club**
- I/We understand that parent/guardian supervision is required to participate in running club. A parent/guardian must be present at all times during running club.

Behaviour Policy

Please ensure that your child wants to attend the program that they are registered for. These programs are not designed or staffed to deal with behaviour issues. A single child’s negative behaviour can seriously impact an entire program and impact the enjoyment for all other participants. Parents will be contacted regarding behaviour issues.

Please ensure you have read and agree to our School District Code of Conduct and Walton Elementary’s Code of Conduct.
The District Code of Conduct can be found here:
http://www.sd43.bc.ca/Board/Policies/Policies/POLICY%2017%20-%20District%20Code%20of%20Conduct%20for%20Students.pdf

Walton Elementary’s Code of Conduct can be found here:
http://www.sd43.bc.ca/elementary/walton/About/COC/Pages/default.aspx

Students who are not able to meet the expectations outlined in the School District Code of Conduct and Walton Elementary’s Code of Conduct may be excused from the activity for the reasons of maintaining a safe and orderly learning environment.

I have read, understand and agree to the Waiver and Behaviour Policy *

Yes

Signature (Type Full Name) *

Date *

By typing your name in the above boxes, you are digitally signing this form.

Submit