North Region Cross Country Booklet

October 2017

Very Important Reminders Bus Drop-off: This year, all busses are to drop off students in one of the parking lots to the south by the ski area. The bus turnaround will also be in a new area. There will be signs to indicate this. No drop offs are to be done at the amphitheater or on the road in front of the community center.

Parking: Parking is only allowed only in the designated parking lots at Earle Bales to the south. Emergency access routes cannot be blocked. Cars not parked in the parking lots will be towed or ticketed at the owner’s expense.

School Seating & Spectators: There is a designated seating area for schools. All participants, coaches and spectators are reminded not to be on the course watching the races or seen to be pacing any runner directly or indirectly. Please set up your school in an area where you can hear the music playing as you arrive.

Washrooms : We may have access to the chalet washrooms provided they are used responsibly by the students participating at the meets. Please be vigilant about sending your school adult supervisors at designated time as per the Washroom Schedule in this package. The main washrooms will be porta pottys located within the designated seating areas. Community Centre: The Community Centre is OUT of BOUNDS at all times.

Garbage in the Park: we ask all students, staff and spectators coming to the cross-country meet 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.

Course Maps and Safety Guidelines have been supplied

TCSAA Athlete’s Pledge

I am the athlete who, through hours of hard work, practice, perseverance and preparation, am here, only by the grace of God, to compete.

With the help of my coaches, the support of my family and friends, I honour the gifts given to me by God. The gift of a strong and healthy body, sound mind and determined heart, the gift of a compassionate spirit and the gift of friendship.

I promise to put forth my best effort within the spirit of the rules. When I fall, I will get up; when I fail, I will try again; when I succeed I will be humble and kind. I will respect my opponent because I know what they have been through.

I ask of the coaches, parents, spectators and fans to respect my teammates and me. Please understand that harsh words and deeds are a negative force. I ask you to represent your school, family and community with dignity. I ask you to encourage us with positive, kind words and remember….we are children of God.

Written by: Joe Gagliardi 2013

North Region Cross Country

********* PLEASE REVIEW CAREFULLY ********** 1. Please make a copy of the booklet for your Principal. 2. Order your buses early. Volunteers please arrive by 9:15am. 3. 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. It is strongly recommended that athletes should compete 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 EpiPen must keep their inhalers/EpiPen 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.

***Results will be emailed to the schools. ***

NORTH REGION ATHLETIC ASSOCIATION On behalf of the North Region Athletic Association, we would like to extend our thanks to:

Master Convenors:

Peter Bernotas – St. Cyril (-5270)

Mario Iozzo – St. Robert (-5297)

Sam Polese – St. Bonaventure (-5263)

Marc Anthony Wong – St. Paschal Baylon (-5283)

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:

David Pagnielloand

Megan Ryan Lamothe

For permits and operational logistics

NORTH REGION CROSS-COUNTRY 2017 SCHEDULE OF EVENTS

“DIVISIONAL EVENTS” EARL BALES PARK

Tuesday

October 10th Meet 1

Wednesday October 11th Meet 2

Thursday

October 12th Meet 3

REGIONAL EVENT EARL BALES PARK

Wednesday, October 18th, 2017

CITY FINALS EARL BALES PARK

Tuesday, October 24th, 2017

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.

2017NORTH REGION

CROSS-COUNTRY GROUPINGS

Final

Divisionals: October 10, 2017 Regional: October 18, 2017 October 11, 2017October 12, 2017

City: October 24, 2017

Locations: Earl Bales (Divisional & Regional)Earl Bales (City)

MEET 1OCTOBER 10

MEET 2OCTOBER 11

MEET 3OCTOBER 12

Blessed Sacrament St. Bonaventure St. RobertSt. Conrad St. Fidelis St. Edward

Saint Kateri St. Norbert Our Lady of WisdomSt. Monica St. Cyril Regina MundiSt. Matthew Sts. Cosmas & Damian Blessed Margherita

Precious Blood St. Timothy St. WilfridBlessed Trinity St. Paschal Baylon St. Raphael

St. Charles Borromeo St. Margaret St. KevinSt. Agnes St. Antoine Daniel Cardinal Carter

Msgr. Charbonnel St. Francis Xavier St. GeraldSt. Matthias Immaculate Conception St. Augustine

St. Charles Garnier St. Francis de Sales St. Jane FrancesD’Arcy McGee Our Lady of Guadalupe Our Lady of Assumption

St. Jerome St. Thomas Aquinas St. GabrielSt. Martha

Revised:July 5, 2017

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

AGE, DIVISIONS, DISTANCE AND ORDER OF RACES

Note: EACH SCHOOL ALLOWED ONLY 8 RUNNERS PER RACE.

***

Grade 8

BOYS 3000m 2004 (or earlier)

Grade 8

GIRLS 2500m 2004 (or earlier)

Grade 7

BOYS 2500m 2005

Grade 4 GIRLS 1500m 2008

Grade 4

BOYS 1500m 2008

Grade 3

GIRLS 1500m 2009 (or later)

Grade 3

BOYS 1500m 2009 (or later)

Grade 5

GIRLS 2000m 2007

Grade 5

BOYS 2000m 2007

Grade 6

GIRLS 2000m 2006

Grade 6

BOYS 2000m 2006

Grade 7 GIRLS 2000m 2005

Remember there is an age restriction to every race.This age is your athlete’s age as of January 1, 2017.

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.

ATTIREAll 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 A LLOWED Students wearing that 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, MAY BE DISQUALIFIED. Adult Course Marshalls can pull a runner who is in obvious physical discomfort or walking. 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. 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 email that included this booklet. 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 may 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 Megan Ryan Lamothe, Resource Teacher to the principal, secretary and the athletic rep. of your school by 8:00a.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 for one of the days of competition. 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. Schools are not allowed to participate unless their volunteers have been placed. 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

Peter Bernotas, David Pagniello or Megan Ryan Lamothe

IMPORTANT INFORMATION FOR COACHES TO NOTE

NAME TAGS: DO NOT PIN! PLEASE KEEP DRY! PUT ON RUNNER JUST BEFORE THEIR RACE on the inside of the collar if

it is wet. 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) Results

Results will be communicated as soon as possible and coaches can go to the Regional Qualifiers or the City Qualifiers tab to review which runners are eligible to run. Please read revised “ADVANCING TEAM” sticker procedures on next pages!!!

SCORING FOR ‘DIVISIONAL’ MEETS, & ADVANCEMENT (October 10, 11,

12)

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.

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, … 60th place = 1 point 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. Officials, at their discretion could ask a runner to abandon the race and report to the scoring table.It is not necessary to enter the maximum 8 runners.

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 TEAM 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 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 second and/or 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 up to the 60th runner 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 First Aid Kit

SCORING AT REGIONAL FINAL MEET & ADVANCEMENT

(October 18th)

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 school will count

towards a TEAM score; B The two TEAMS with the highest point totals will

advance to CITY finals, no matter where the TEAM members finish in the race.

C A 4th, 5th, 6th, etc. 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

Wednesday, October 18th, 2017 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 school may enter a maximum of 8 runners in any race. The scoring software will keep track of this number for each school in every race to ensure compliance. Non-compliance may lead to disqualification in that race.

*****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 runner finishes or in bundles at the announcer’s table.

f) There will be up to 8 RIBBONS for winning runners of each

race.

II) REGIONAL FINALS a) A PLAQUE will be presented to the overall winning school. b) PENNANTS will be awarded to 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 of THREE runners. A

school may send up to a maximum of 8 runners per race if they qualified in the DIVISIONAL Meet, and FOUR from the Regional Meet if they qualified.

3 Therefore, if an advancing TEAM’S 2 nd and/or 3rd qualifying

runner finishes after the first 22 runners (i.e. 23rd, 24th, 25th, etc), that runner WILL ADVANCE to the next meet. (See Example Below).

4 However, a 4th, 5th, 6th, 7th, or 8th qualifying runner must finish

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

NOTE: a) Only the TOP 3 runners from a school in any race are used for TEAM 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 totaled. 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) TEAM-1 totaled 152 points and TEAM-2 totaled 151 points

(from the top 3 finishers).

b) All three of TEAM-1’s runners advance (minimum required), even though the third runner was 24th*.

c) All SIX of TEAM 2’S school’s runners advance because all six placed in the first 22 finishers, the top 3 running as a TEAM.

d) In this particular case a total of 23 runners will advance to the next meet instead of the usual 22.

WASHROOM SCHEDULE Divisional Meet

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

TIME MEET 1

OCTOBER 10MEET 2

OCTOBER 11MEET 3

OCTOBER 129:40 Blessed Sacrament St. Bonaventure St. Robert

10:00 St. Conrad St. Fidelis St. Edward

10:20 Saint Kateri St. Norbert Our Lady of Wisdom

10:40 St. Monica St. Cyril Regina Mundi

11:00 St. Matthew Sts. Cosmas & Damian Blessed Margherita

11:20 Precious Blood St. Timothy St. Wilfrid

11:40 Blessed Trinity St. Paschal Baylon St. Raphael

12:00 St. Charles Borromeo St. Margaret St. Kevin

12:20 St. Agnes St. Antoine Daniel Cardinal Carter

12:40 Msgr. Charbonnel St. Francis Xavier St. Gerald

1:00 St. Matthias Immaculate Conception St. Augustine

1:20 St. Charles Garnier St. Francis de Sales St. Jane Frances

1:40 D’Arcy McGee Our Lady of Guadalupe Our Lady of Assumption

2:00 St. Jerome St. Thomas Aquinas St. Gabriel

2:20 St. Martha

2:40

WASHROOM SCHEDULE North Regional Meet

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

9:40 Blessed Sacrament St. Bonaventure St. Robert

10:00 St. Conrad St. Fidelis St. Edward

10:20 Saint Kateri St. Norbert Our Lady of Wisdom

10:40 St. Monica St. Cyril Regina Mundi

11:00 St. Matthew Sts. Cosmas & Damian Blessed Margherita

11:20 Precious Blood St. Timothy St. Wilfrid

11:40 Blessed Trinity St. Paschal Baylon St. Raphael

12:00 St. Charles Borromeo St. Margaret St. Kevin

12:20 St. Agnes St. Antoine Daniel Cardinal Carter

12:40 Msgr. Charbonnel St. Francis Xavier St. Gerald

1:00 St. Matthias Immaculate Conception St. Augustine

1:20 St. Charles Garnier St. Francis de Sales St. Jane Frances

1:40 D’Arcy McGee Our Lady of Guadalupe Our Lady of Assumption

2:00 St. Jerome St. Thomas Aquinas St. Gabriel

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.

Race 1 10:30 Grade 8 3000m BoysRace 2 10:45 Grade 8 2500m GirlsRace 3 11:00 Grade 7 2500m BoysRace 4 11:15 Grade 4 1500m GirlsRace 5 11:30 Grade 4 1500m BoysRace 6 11:45 Grade 3 1500m GirlsRace 7 12:00 Grade 3 1500m BoysRace 8 12:15 Grade 5 2000m GirlsRace 9 12:30 Grade 5 2000m BoysRace 10 12:45 Grade 6 2000m GirlsRace 11 1:00 Grade 6 2000m BoysRace 12 1:15 Grade 7 2000m Girls

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.

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.

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”.

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.

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.

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 jewelry must not be worn. Jewelry 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.

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:

______________________________________________________________ Orthopedic 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:

______________________________________________________________

Headac

hes:

__________________________________________________________

____ 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: ___________________________________________

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

PLEASE NOTE: FREEDOM OF INFORMATION

The information on this form is collected under the authority of the Education Act, R.S.O. 1991, Section 170(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.