Field Trip Forms

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Field Trip Forms

  1. 1. Puyallup School District Form 2320F1 Field Trips, Excursions and Outdoor Education Instruction Step 1 - Request for Field Trip School Destination Applicant Departure Date Time Date of Application Return Date Time Purpose of Trip (application to the curriculum): Itinerary: Person in Charge: Type of Event (parade, contest, etc.) ___________ Number of Teacher Chaperones: __________ Groups participating (orchestra, debate team, etc) Number of Parent Chaperones: __________ _______________________________ Number of Participating Students: _________ TRANSPORTATION: Cost $___________________ (Type: School bus, chartered bus, ferry, etc) If bus is to be used, the following must also be completed: Call transportation for estimate if District buses are used. ESTIMATED COST: ________________ Recorded by _____________________ (Transportation personnel) Cost figured on basis of ________ buses. Date: __________________________ HOUSING: ____________________________________________ Cost $__________________ (Type: Motel, hotel, dorm, private home, etc.) FOOD: ________________________________________________ Cost $ __________________ (Group Meals – Number of meals) OTHER COSTS: ________________________________________ Costs $ _________________ (Sightseeing, entrance fees, extra insurance coverage, etc.) TOTAL COSTS OF TRIP………………………………………………………$_______________ Source of Funds: Building Budget: Account code ______________________________costs $_________________ Student Body: Account code ______________________________ costs $_________________ Individual Students: ______________________________ costs $_________________ Other funding source: _______________________________________costs $_________________ Approved by ASB Treasurer (if student body funds are used):_____________ Date: ______________________ Approved by Principal: _________________________________ _ Date: ______________________ Approved by Director of Athletics: __________________________Date: ______________________ Approved by Chief Academic Officer: Date:______________________ Approved by the Superintendent:___________________________ Date: ______________________ If in state, submit this form to building administrator for signature and route to Chief Academic Officer for approval 30 school days (6 weeks) prior to the field trip activity. If in state overnight, submit this form to building administrator for signature and route to Dir. of Athletics, Chief Academic Officer for approval and Superintendent approval 30 school days (6 weeks) prior to the field trip activity. If out of State (ALL States), submit this form to building administrator for signature and route to Dir. of Athletics, Chief Academic Officer for approval and Superintendent approval 60 school days (12 weeks) prior to the field trip activity. International Travel, submit this form to building administrator for a signature and route to Chief Academic Officer for approval and Superintendent for approval 60 school days (12 weeks) prior to the Board meeting.
  2. 2. Puyallup School District Form 2320F2 Field Trips, Excursions and Outdoor Education Instruction Puyallup School District Consent form for Curriculum Related Activities School: _______________________________ Teacher: Student’s Name: (first & last) Will be participating in the following activity: This involves: On: Itinerary attached ________________________________ (date of activity) Teacher’s Signature This activity provides a learning experience for the students and allows them an opportunity to apply their classroom learning. TYPE OF TRANSPORTATION: District Vehicle Commercial Transportation * Private vehicle – driver’s name: • If a private vehicle is used, the individual driver is responsible for carrying valid liability insurance and maintaining the vehicle in safe working condition. The District does not encourage use of private vehicles to transport elementary students. In the event of an accident or illness, I understand that every reasonable effort will be made to contact me immediately. However, if I am not available, I authorize the Puyallup School District to secure emergency medical care as needed. Although I understand that the Puyallup School District will make every reasonable effort to provide a safe environment, I am fully aware of the special dangers and risks inherent in participating in the activity, including physical injury, or other consequences arising or resulting from the activity. Being fully informed as to these risks, I hereby consent to the student participating in the activity. Parent/Guardian Name: Student: Home Address: Telephone: (signature of parent/guardian) (date)
  3. 3. Puyallup School District Form 2320F3 Field Trips, Excursions, and Outdoor Education Instruction Puyallup School District Consent Form for Noncurriculum Activities School: _______________________________ Teacher: Student’s Name: (first & last) Will be participating in the following activity: This involves: On: Itinerary attached ________________________________ (date of activity) Teacher’s Signature This activity provides a learning experience for the students and allows them an opportunity to apply their classroom learning. TYPE OF TRANSPORTATION: District Vehicle Commercial Transportation * Private vehicle – driver’s name: • If a private vehicle is used, the individual driver is responsible for carrying valid liability insurance and maintaining the vehicle in safe working condition. The District does not encourage use of private vehicles to transport elementary students. In the event of an accident or illness, I understand that every reasonable effort will be made to contact me immediately. However, if I am not available, I authorize the Puyallup School District to secure emergency medical care as needed. Student’s name has my permission and authorization to participate in the above- named activity. I am fully aware of the special dangers and risks inherent in the activity, including physical injury or other consequences that may arise or result directly or indirectly from the activity. Being fully informed as to the risks and in consideration of the privilege of participating in the above described activity, I hereby assume all risk of injury or liability and waive any right of recovery from or to bring suit against the Puyallup School District, its officers, agents, and employees for any personal injury or other consequences arising out of participation in the activity, except for the sole negligence of the school district. I certify that I am the parent or legal guardian of the participant named above; that I have read and understood the foregoing release: and that I join in the release without reservation, granting full consent and authorization for the above person to participate in the activity. (signature of parent/guardian) (date) Parent/Guardian Name: Student: Home Address: Telephone:
  4. 4. Puyallup School District Form 2320F4 Field Trips, Excursions and Outdoor Education Instruction Puyallup School District Student Personal Medical Insurance Coverage Field Trip or Tour Use Only Student Name: Address: City: Zip: Birthdate: Grade: Sex: Home Telephone: Parent/Guardian Name: Work Telephone: Name of person to call in case of an emergency when the parent/guardian is not available: Emergency Contact: Telephone: Family Doctor: Telephone: Medical restrictions of student: The Puyallup School District does not carry insurance to cover medical treatment of students. Parents should consider obtaining student accident insurance as a supplement to any other health insurance they may maintain. Accident Medical Insurance Information: The above named student is covered by the following personal medical/dental: Medical Insurance: Policy No: Dental Insurance: Policy No: Student Insurance: Policy No: In the event of an accident or illness, I understand that every reasonable effort will be made to contact me immediately. However, if I am not available, I authorize the Puyallup School District to secure emergency medical care as needed. Signature of Parent/Guardian Date: District use: Keep this form in the student’s cumulative file for one school year.
  5. 5. Puyallup School District Form 2320F5 Field Trips, Excursions and Outdoor Education Instruction Puyallup School District Volunteer Request for Authorization to Transport Students Any volunteer, who transports students for school activities in a private vehicle, must complete and submit this form to the building administrator for approval. Volunteers are not authorized to transport students until they receive notification from the building administrator that their request form has been approved. Approval to transport students is only valid for the date(s) indicated. If deemed necessary, the Puyallup School District reserves the right to request a volunteer’s Abstract of Driving Record from the Department of Licensing. Name of driver (Last, First, Middle)_____________________________________________ Drivers’ License #:____________________State:____ Expiration Date: ___________ Auto Liability Insurance Carrier: Agent: _________________ Phone No: Policy No:_______________ Exp. Date: ___________ Circle Yes or No: • Yes No I am at least 21 years of age. • Yes No I have a valid Washington State driver's license. • Yes No I have an active auto liability insurance policy (policy information provided above) that carries the State minimum, or greater, limits of coverage. The policy includes coverage for general liability, bodily injury, property damage, and uninsured/underinsured motorist (for use when driving students in your personal vehicle). • Yes No I understand that If I am involved in a motor vehicle accident while driving my personal vehicle on school related business, that my personal auto insurance policy will be considered the primary insurance coverage, and that any and all claims will be submitted to my personal insurance carrier for payment. The Puyallup School District’s liability insurance coverage will be considered secondary coverage, and applicable only after all limits under my personal insurance policy have been exhausted. • Yes No I certify that my vehicle has no known mechanical defects, and no known safety deficiencies. • Yes No I certify that all occupants of any vehicle I use to transport students will be required to individually wear a seat belt, including both the driver and passengers. If the vehicle I am driving to transport students is equipped with a passenger side air bag, I will not allow any student to ride in the front passenger seat if they are less than 12 years old, or weigh less than 100 pounds. • Yes No I understand that I may only transport students in vehicles with a rated capacity 0f 10 passengers, including the driver, or less. Any vehicles with a greater than 10 passenger rated capacity are prohibited. • Yes No I agree to report to the school principal (or designee) regarding any and all accidents, regardless of how minor, that I am involved in while transporting district staff, volunteers, or students. • Yes No I certify that I have no known medical condition that would adversely affect by ability to safely transport students in a motorized vehicle.
  6. 6. • Yes No I have had a moving [vehicle] violation(s) within the last three (3) years. (If “Yes,” list violation and date): Violation: Date: Please note that no person shall be authorized to transport students for the Puyallup School District, if in the preceding three(3) year period, has been convicted or cited by lawful authority for the following: 1. DUI/DWI 9. More Than Two Citations in a 3-year period 2. Deferred Prosecution 10. Suspended License – Moving and Administrative Action 3. Negligent Driving 11. Failure to Appear 4. Reckless Driving 12. Vehicular Homicide 5. Open Container Violation 13. Vehicular Assault 6. Speeding (11 MPH or more excess) 14. Road Rage 7. Violating License Restrictions 15. Hit and Run Driving 8. Illegal Drugs 16. Other Citations (as deemed appropriate) I certify that I have answered all of the above questions truthfully and have not withheld any information. Signature Date * Before submitting this form for approval, please attach a photocopy of your current driver’s license and proof of insurance. ________________________________________________ ______________ ____ For Approving Authority Use Only: _____ Washington State Patrol background check conducted. _____ All students have parental permission to ride with a volunteer driver. The above individual’s application is: APPROVED DENIED Dates this volunteer is approved to drive students: __________________to _______________ _____ Signature Title Date

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