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530 East 41st Avenue Vancouver, BC V5W1P3

Telephone: 604-713-5520              Fax: 604-713-5528                 Website: http://vlns.ca


Teacher: Ms. Mattu, Ms. Mah, Ms, Qi, Ms. Cormack, Ms. Horng          Course for Field Studies: Science, Technology, Engineering and Math Extension


To the Parent(s)/Guardian(s) of: _____________________________________________________  Grade: ________________


The purpose of this form is to inform you about a proposed field studies involving your child, and to seek your support and permission for your child to participate.  Field studies are part of the school program and they provide students with valuable learning experiences.  However, should you not wish your child to participate in this activity, school staff will assign the student other learning activities at the school.


This is an important document.  Please review the contents of this Consent and Acknowledgement of Risk form carefully prior to providing permission for your child to participate in this excursion.  Clarify any questions or concerns with the Lead Teacher BEFORE signing it.


If this form is not signed and returned to the school by 2016/02/23,








DESTINATION/ACTIVITY: Room 117A of the VLN                                 DATE(S): February 23, 2016


ACTIVITIES TO BE UNDERTAKEN (be specific ): Students will build a marble-sorting machine as stipulated by the rules of the Fluor Engineering Challenge 2016. Details are here.


PURPOSE OR EDUCATIONAL GOAL(S): Students will work on the following Competencies identified in the new BC Science Curriculum:

  1. Compare results with predictions suggesting possible reasons for finding. (G3)
  2. Demonstrate  a sustained intellectual curiosity about a scientific topic of personal interest. (G3)
  3. Identify a question to answer or problem to solve through scientific inquiry. (G3)
  4. Co-operatively design projects. (G3)
  5. Generate and introduce new or revised ideas when problem solving. (G3)
  6. Make predictions/inferences based on prior knowledge. (G3)
  7. Transfer and apply learning to new situations. (G3)


9:30 AM: Opening remarks and instructions.

9:45 AM: Building time. Students may also look at other projects. When ready, students may call teachers to score their machines and                    

                have individual photos taken.

   10:45 AM: Break. Students may continue building.

11:00 AM: Building and scoring. Gallery walk.

11:45: Closing Remarks

METHOD OF TRANSPORTATION: Students are responsible for travelling to the VLN.




OTHER TRIP SUPERVISORS:  Mr. Rutley, Ms. Mattu, Ms. Mah, Ms, Qi, Ms. Cormack

COST TO THE STUDENT: No cost.   WHAT TO BRING: We will supply all required building materials. We will have some utensils for cutting etc. but students may bring their own utensils if they wish.


BEHAVIOUR EXPECTATIONS: Students are expected to be respectful of themselves, others and the environment.




The board will make every reasonable effort to ensure or ascertain that:

a.   The staff, volunteers and/or service providers involved are suitably trained and qualified.

b.   The students are adequately supervised over all aspects of the program/activity.

c.   The location(s) used are appropriate and safe for the activity(ies) and group.

d.   A Safety Plan is in place to identify and manage known potential risks.

e.   An Emergency Plan is in place to deal with an injury or illness to any of the students.






This section outlines potential risks of participation in the field study and includes safety issues and precautions which have been discussed with students, (e.g. if students are required to wear specific safety equipment, such as goggles or helmets.  






Students will be using scissors.


Safety issues & precautions:








Administrator’s Signature








Destination/Activity/Program: ___________________________________________________  Dates: ___________________________


While school staff will take reasonable steps to prevent injuries to students, some degree of risk is inherent in the nature of this activity, 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 your child to participate in this activity, you are agreeing that the activity described above is suitable for your child, and that there is a risk of injury associated with the activity.


·        My child has been informed that he/she is to abide by the rules and regulations, including directions and instructions from the school’s and/or service provider’s administrators, instructors, and supervisors over all phases of the program/activity.

·        In the event my child fails to abide by these rules and regulations, disciplinary action may require his/her exclusion from further participation or that I be contacted to have him/her picked up, unless I have specified other transport arrangements.

·        I acknowledge that the trip supervisors may secure transport to emergency medical services as they deem necessary for my child's immediate health and safety, and that I shall be financially responsible for such services.


I, ____________________________________________________________________ (parent/guardian) give permission for

________________________________________________ (student)  to participate in the field study described above.

I understand that my child may be exposed to a risk of injury due to accident while participating in this activity.

Date: ___________  Name (Please print): ______________________________  Signature: _________________________________


Parent/Guardian Contact Numbers: Day __________________  Evening ____________________  Cell ________________________


Comments (please include below any restrictions or limitations which would prevent your child from fully participating in this trip, or any other special concerns which Board staff should be aware of surrounding your child.)



NOTE:  Efforts to minimize costs have been made to support student participation.  In accordance with Board policy JN Students Fees, Fines and Hardship no student shall be denied an opportunity to participate in an activity because of an inability to pay fees.  Please contact the teacher or Principal if you have questions or concerns regarding the amounts listed above.

Medical Information For Field Studies

The collection and retention of information requested on this form is authorized and governed by the BC School Act and the Freedom of Information and Protection of Privacy Act

(Please print carefully and legibly)            The following information is required in the event of the need for medical services.


Student Name: ____________________________________________________________  Birth Date: ________________________

Address:  ____________________________________________________________________________________________________

Grade:___________   Grade Counsellor:_____________________________    Grade Administrator _____________________________

BC Medical Services Plan Personal Health No.: __________________          Student School Accident Insurance:          o Yes  o No


Allergies (e.g., specific drugs, foods, insect stings, hay fever) Specify:_____________________________________________________


Reaction(s) to above? ______________________________________  Date of last Tetanus shot: _______________________________


Carries Epi pen? o Yes  o No              Inhaler? o Yes  o No             Medical Alert Bracelet? o Yes  o No

Medical/physical conditions that may affect participation in the field studies (e.g., illness, injury, recent hospitalization/surgery, conditions, phobias, etc.).



Specify activities your child should not participate in or modifications they may require to participate in the field studies



Prescribed medication(s) taken at this time (name, reason, dosage, storage, potential side effects/treatment of such):




Other Health/Medical/Dietary Concerns/restrictions: ________________________________________________________________

Emergency Contacts:

1) ____________________________________ Phone: (H) __________________ (W) ________________  (C) ________________


2) ____________________________________ Phone: (H) __________________ (W) ________________  (C) ________________


Name of Physician:                                                                                                                                     Phone #

A C K N O W L E D G E M E N T   O F   C O N S E N T


Specify Parent/Guardian relationship who is filling out and signing this form:_________________________________________________


Should it become necessary for my child to have medical care, I hereby give the teacher permission to use his/her best judgment in obtaining the best of such service for my child.  I understand that any cost will be my responsibility.  I also understand that in the event of illness or accident, I will be notified as soon as possible via the emergency contact information listed above.


Name (please print) _______________________________________  Signature __________________________________________


·        The above mentioned student has parental permission to attend the field trip with the understanding that missed assignments will be completed on the student’s own time.

·        Field trip sponsor teacher must ensure that this form is filled out prior to students requesting subject teacher’s signatures.




Student is responsible for missed curriculum

Students must record this information in their agenda


































Off T/T