Week Without Walls

Parental Authorization Form

Student Information Form

For more information about the Week Without Walls trips please click here

The Week Without Walls Outdoor Education Program is a core part of the school programme, all students are expected to participate.

Student First Namerequired

Student Family Namerequired

Classroom Teacherrequired

Homeroom Teacher/Advisorrequired

Parent/Guardian Namerequired

Parent Mobile Numberrequired

Home Phonerequired

Emergency Contactrequired

Relationshiprequired

Emergency contact phone numberrequired

Student Information

Heightrequired

cm

Weightrequired

kg

Bike Riding*

Please select your bike riding ability

Have never ridden a bike Beginner - slow but can ride Intermediate - could ride between 10 - 20km Experienced - could ride 20+ km in a day

Swimming Ability*

Please select your swimming ability

Cannot swim Beginner - swim less than 25m Confident - swim more than 25m

Dietary Information

Any dietary restrictionsrequired

Note about any dietary restrictions

Dietary restrictions are only those due to allergies, religious, personal beliefs, cultural reasons. ie not personal preference of food type

Health Information

Any Allergies*

No Yes

Allergies

Please specify any allergies including food allergies.

Allergy treatment

Please describe the treatment in the case of an allergic reaction

Other health concerns

If your child has any other health concerns please specify

Medication Authorization

The administration of medication to students on field trips shall be done by the teacher who will be responsible for storing and administering medication on the field trip.

Personal Medication*

Will you bringing personal medication (from home) on this trip

No Yes

Please download the form “AUTHORIZATION FOR MEDICATIONS TO BE GIVEN” and submit it with the medicines to the Health Office before the trip.

Click here to access form

Inhaler

Will you child be carrying an inhaler on the trip?

Yes No

Epi-pen

Will you child be carrying an Epi-pen on the trip?

Yes No

Medication administration*

In the event of a minor illness, I authorize the supervising teacher to administer any of the following over the counter medications to my child

Acetaminophen (Tylenol) アセトアミノフェン（解熱鎮静剤） Ibuprofen イブプロフェン　（解熱消炎鎮痛剤） Antacid 胃酸を抑える薬／胃腸薬の一種 Antihistamine　抗ヒスタミン剤 Topical Ointments　局所用軟膏 No medications to be administered

Rules and Authorization

I, the parent/guardian have read, understand and approve of the rules. I understand the arrangements and believe that the necessary precautions and plans for the care and supervision of the children during the trip will be taken. I also give permission for him/her to participate on the field trip and will assume full responsibility for any and all medical expenses incurred during the trip.

Japanese Health Insurance

My child has Japanese Health Insurance 私の娘／息子は、日本の健康保険証を持っています

Yes No

Japanese Health Insurance card

Please attach a copy of the Japanese Health Insurance 日本の健康保険証のコピーを添付します

Max file size: 10 MB

Parent/Guardian Permission*

I, the parent/guardian, give permission for my son/daughter to participate in the Week Without Walls Program.

I give permission

Student Agreement*

Students must understand and observe, and parents must support the following: All school policies and regulations will be in effect according to the student handbook. Student cell phones are not allowed. Any infraction or misconduct during a trip will result in disciplinary measures. These measures may include the student being sent home at the expense of the parent/guardian. Serious behaviour infractions may also result in the student not be eligible to travel on other overnight trips such as APAC or WJAA. I, the student, have read and understand the above rules and possible disciplinary measures.

I agree (Student)

ACTIVITIES DISCLAIMER EVERGREEN OUTDOOR CENTER

This disclaimer is required by Evergreen Outdoor Center, the company running the Grade 9, 11 & 12 trip.

Please read the following disclaimer thoroughly and click "I agree" if you are in agreement with all conditions.

Please have your son or daughter read the following to you as a statement of their
acknowledgement:

I will listen and comply with the instructions and rules of the Evergreen Outdoor Center and its
staff for my and others safety and favorable experience.

I will try to prevent personal and secondary injury through my own responsible and safe conduct
at all times.

I will stay with the group so as not to get lost and also to reduce the risk of not receiving the
proper medical attention or rescue in the event of an accident.

I will, knowing my own ability, stay within my capabilities for the safety of myself and others.

I will, in the event of an accident, act in the manner best suited for the situation at hand with the resources available (eg: self rescue, receiving assistance from others or Evergreen Outdoor Center
staff).

The following is for a parent or legal guardian to read and sign for consent for your son or daughter to
take part in the adventurous activities provided by Evergreen Outdoor Center.

Evergreen Consent*

I recognize and understand the inherent risks of the outdoor sports that the Evergreen Outdoor Center provides. I recognize that taking part in the outdoor sports that the Evergreen Outdoor Center provides could result in injury, death or damage during activities or transportation to and from activities. Understanding that the Evergreen Outdoor Center as a professionally run adventure outfitter will take every precaution to reduce the risk associated with outdoor sports, I realize that incidents may be unavoidable. Understanding the above stated I allow my child to take part in the outdoor sports activities as provided by the Evergreen Outdoor Center, their staff and associates.

I agree

Consentrequired