PLAN 313 - Community Design Studio Field Trip - Spring 2024

PLAN 313/647  Community Design Studio has a field trip scheduled for Tuesday, June 4th to Earthscape in Wallenstein, ON. Pick up will be at 2:15 PM at the UWaterloo Environment 3 Ring Road entrance. Estimated return 5:30PM.

There is a $30 (HST Included) fee required for this trip, payment can be paid online here. 

Completion of this form and payment are a requirement to participate in this field trip. Exceptions to be discussed with the instructor. 
I am Registered in PLAN 313 - Spring 2024
The instructor has discussed appropriate safety protocols with the class. (see announcement on course LEARN site)
I will be participating in the trip scheduled on June 4th.
Do you have a Student Supplementary Health Plan?
If you indicated no above, list your insurer(s) and policy number.
Emergency Contact
Emergency Contact
Please ensure that your Emergency Contact has copies of your personal information including OHIP/UHIP number, medical/travel insurance coverage, blood type and any information such as allergies, drug sensitivities, regular medications and other information (e.g., medical condition) that might be of significance to the university, a physician or hospital treating you in any emergency situation.  I have fully informed the Emergency Contact regarding all aspects of my travel, including the nature of possible risks.  Student guarantees that medical insurance is in force for the duration of the off-campus program and in the case of Emergency, consents to the release of personal information.

Acknowledgement of Risk and Responsibility

I have reviewed, understand and  acknowledge that I have complied with the information provided on the University of Waterloo Acknowledgement of Risk and Responsibility form.  I understand the university does not provide insurance coverage for field trip participants.

I acknowledge that travel to these sites is to be arranged by students using active transportation, public transportation, or private vehicles. I acknowledge that travel in private vehicles carries risks that cannot be guaranteed by the University, and I will confirm that the owner of any vehicle I travel in has personal liability insurance coverage.

I agree that In the event of a first aid or medical emergency I will call 911. 

Risk Acknowledgement

Policy 33

I have reviewed, understand and agree to the information provided contained in Policy 33 and I am aware that disciplinary action may be taken within the University and/or charges laid under the Human Rights Code against individuals who are found guilty of such offences. Full details of University policy are available under Policy 33, Ethical Behaviour https://uwaterloo.ca/secretariat/policies-procedures-guidelines/policy-33

Policy 33

Policy 34

I have reviewed, understand and agree to UW Policy 34 https://uwaterloo.ca/secretariat/policies-procedures-guidelines/policy-34 in particular, “Each faculty member, staff member, student, visitor and contractor has primary responsibility for their own safety and actions, and for others affected by their actions.” and “All members of the University community must report to their supervisor any hazardous conditions which are contrary to good health, safety or environmental practices or which contravene any legislative requirements.”

Policy 34

Policy 71 

I have reviewed, understand and agree to the information provided contained in Policy 71 and I understand the instructor retains the right to send the participant home at my expense according to UW Policy 71 Student Discipline https://uwaterloo.ca/secretariat/policies-procedures-guidelines/policy-71.

Policy 71
Notice of Photography
Photos and videos taken during this University of Waterloo event may be published, placed on the internet, exhibited or reproduced for future marketing or promotional activities for the university. By agreeing to this statement, you understand that photos may be taken and shared by the School of Planning at our discretion in future. 
Notice of Photography Agreement