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“A” Off-Site Activity Proposal - Single Activity

Corporate Risk Management

Conditions: This form is filled out by the teacher-in-charge who submits the form to the school principal for approval. The “A” approval process is detailed in the Off-Site Activities Procedures Manual.
Once the Principal has approved this off-site activity:
  • Fax a copy of the proposal to Corporate Risk Management at 403-294-8458 one (1) week prior to the trip

School:
Tom Baines School / Phone:
777-7190 / Fax:
777-7191 / Area:
1
Destination:
Military Museum / Departure Date: Oct 29/08 / Return Date:Oct 29/08
Departure Time: 9:15 AM / Return Time:12:30 PM
Area of Study (as defined in the program of studies):
Drama/Debate / Purpose of Trip:
Experience Tour
Grade Level (Please check all that apply):
ECS 1 2 3 4 5 6
7 8 9 10 11 12 SP / # of Students :
30 / Male:15
Female:15
Contact phone number of the teacher-in-charge during the field trip:403-613-4172
Facility: Cell No. 403-613-4172Satellite No. (if applicable)
Supervision / Gender / What curriculum areas are taught? / Date of last visit to site: / Will you be present for the entire trip? If not, specify schedule. / List relevant Certifications
(e.g. Level of first aid, etc.)
(appendix 2 and chapter 7)
Teacher-in-charge
Karena Munroe /
F /
Drama /
October 2007 / Yes
Staff: (list)
Jen Kenyers /
F /
Hum /
October 2007 / Yes
Volunteers: (list)
1 /
TBA /
N/A /
N/A
Have all volunteers completed the Volunteer Clearance process?YesNo
Volunteers
All volunteers must complete the requirements of Policy 5003 – Volunteers.
  • Indicate what training and knowledge is required of the volunteers for this off-site activity. Volunteers must have general participation guidelines, and a list of students to attend to.
  • How have you prepared the volunteers to assist with the supervision of this off-site activity?Each volunteer will be given a list of guidelines and a list of students

Supervision
Students must be supervised at all times.
  • What is the supervision ratio during transportation? 1:10
  • What is the supervision ratio during the activity? 1:10
  • What are the responsibilities for supervisors (other teachers and volunteers) and how have such expectations been communicated? They are responsabile for student's safety, attendance, wherabouts and appropriate behaviour. These expectations have been verbally communicated and each volunteer has written guidelines and an attendance group sheet.

Method of Transportation (chapter 4)
School-owned Van (name of employee , class of license of driver )
School-owned Bus (name of employee , class of license of driver )
Rental Van (name of company ) (name of employee , class of license of driver )
Arranged by Service Provider
Charter Bus (name of company Southland)
No transportation provided by school
Other:
Has the CBE employee completed the Driver Agreement for School Staff? YES NO
Has a Driver Abstract been provided? YES NO
Volunteer Driver (parent/coach) , class of license of driver
Has the volunteer completed the Volunteer Driver Agreement YES NO
Has a Driver Abstract been provided? YES NO
Complete If using a Service Provider
Name of Service Provider: / Service Provider Contact Person: / Phone Number of Service Provider:
mailing address: / city/town: / e-mail:
  • Explain the role of the service provider during the off-site activity?
  • What role does the service provider have with regards to the preparation of the off-site activity?

RESTRICTED ACTIVITIES
Please indicate any and all of the following activities that are planned for this Off-Site Activity.
For the activities marked, the teacher-in-charge must comply with the activity requirements listed in the Off-Site Manual
Acitivity/ies
Athletics Ice Skating Sailing
Backpacking International Travel SCUBA
Canoeing-Flat Water Kayaking-Flat Water Skiing & Snowshoeing
Canoe Tripping-Flat Water Kayaking-Moving Water Skiing & Snowshoeing-Backcountry
Canoeing-Moving Water Kayaking in Sheltered Water Skiing-Cross Country
Canoe Tripping-Moving Water Kayak Tripping in Sheltered Water Skiing & Snowboarding-Downhill Facility
Cycling Luge Snowshoeing
Fine and Performing Arts Mountain Biking Swimming
Hiking Rafting Urban Pathways
Horseback Riding Rock Climbing Wall Climbing
Accommodations
Billeting
Hotel Accommodations

RM - “A” Off-Site Activity Proposal – Single Activity Updated August 2008

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EDUCATIONAL ASSESSMENT
Itinerary / Learner Outcome
CBE Educational Ends and/or Program of Study
Curriculum Connection / Method of Assessment
Activity / Location
Military Tour and Viewing / Military Museum / •Facilitating the learning of abstract concepts
•Motivating students through increased interest and curiosity
•Improving long term retention of concepts
•Teaching method by example
•Developing social consciousness an increased appreciation for the phenomenon studied
•Learning is seen as a practical component of life versus a structured classroom activity / Participation in subject debate culminating activity

RM - “A” Off-Site Activity Proposal – Single Activity Updated August 2008

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Requirements Checklist
(Complete and attach the following forms to the template when submitting to the Principal for approval)
Consent and Acknowledgement of Risk - Student
Consent and Acknowledgement of Risk – Volunteer
Parent letter
Swimming Ability Form (if applicable)
Detailed Itinerary
If using a Service Provider attaché the Service Request
Trip Preparation
The teacher-in-charge is responsible to have a field trip resource kit. This will include as a minimum: appropriate first aid kit; communication device; emergency response plan and a photocopy of the student medical information (original must remain at the school).
The Occupational Health and Safety First Aid Regulations must be followed.
As the Teacher-in-Charge:
  • What preparation have you undertaken to gain familiarity and check the appropriateness of the site (terrain, equipment, hotels, buses, etc.)?
I have been there before.
  • What effects will weather have on this off-site activity?
Very little, transportation effects, level of dress.
  • How have you prepared the students’ skills, knowledge and attitude for the off-site activity?
2 weeks (4 classes) and school code of conduct
  • How will you assess the student’s individual readiness?
Class discussion, student observation.
  • How have you ensured that parents and students have received all pertinent information regarding this trip, including emergency procedures?
Yes, letter home.
  • What contingency plans exist (e.g. trip cancellation both prior to and during the trip, weather delays, missed flights, etc. including how funds will be accessed.)
If trip is cancelled students will go to regular classes and will be reimbursed if possible.
  • What are the expectations of student behaviour during the off-site activity?
Polite, safe and respectful, as they behave in school.
  • Discipline of students is the responsibility of the teachers. Students who fail to follow instructions or are disrupting the activities of the group should be removed from the group and be dealt with by the Teacher-in-charge.
  • What are the consequences of inappropriate behaviour and how has this been communicated to students and parents?
Students who misbehave may have to sit out during the trip and write apology letters, we have a zero tolerance policy for inappropriate behavior.
  • How have the students been prepared with respect to the hazards listed below?

RM - “A” Off-Site Activity Proposal – Single Activity Updated August 2008

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Complete the chart below to indicate the hazards of this trip. List all the activities including transportation that will occur during the trip. List all the hazards (cause of accident) in relation to the identified activities. List the precautions that have been made to minimize the risk.
activity
/
hazards (Cause of Injury)
/
precautions taken
Transportation
/
those associated with road travel such as colisions and weather
/
Approved carriers
Walking
/
injuries associated with walking - strains, sprains and fractures, allergies
/
we will enforce safe behaviour

RM - “A” Off-Site Activity Proposal – Single Activity Updated August 2008

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Emergency Procedures (Chapter 6)
General:
  • Teacher needs to familiarize themselves with the Emergency Procedures in the Off-Site Activities Procedure Manual and carry a copy with them on the Off-Site Activity.
  • What is the process to activate emergency services (Police, Fire, Ambulance, Search and Rescue) in the area of the off-site activity?911
  • Is the off-site activity in a rural, urban or remote area? No
  • The teacher-in-charge is the first response during an emergency. The school is requested to supply a first aid kit, cell phone and further communication devices (e.g. two-way radios) if there is more than one group. The teacher or supervisor needs to be certified in First Aid
  • What steps will be followed if a student is ill or has a non-life threatening injury?
Treatment will be given as necessary; school administration contact; parent contact.
  • What steps will be followed if a student has behavioural issues? The student and one of the supervising teachers will leave the tour and will write an apology letter
  • An accident report needs to be completed and filed.

Name of Teacher-in-charge (please print)
Karena Munroe / Date (year/month/day)
2008/09/30 / Signature of teacher-in-charge
I have reviewed, discussed and APPROVE this trip.
Name of Principal (please print)
Darlene Selby / Date (year/month/day)
2008/09/30

RM - “A” Off-Site Activity Proposal – Single Activity Updated August 2008

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