Out-of-Town Field Trip Request (Over 50 Miles/ Overnight)

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Peregrine Cook
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1 FOR TRANSPORTATION USE ONLY Invoice #: Out-of-Town Field Trip Request (Over 50 Miles/ Overnight) Today s Date: Trip Date: NOTE: Form must be approved ten days prior to the trip. School: Grade-Class Level: Ages: Destination: Departure date: Departure time: : AM / PM Return date: Return time: : AM / PM NOTE: All field trips must be directly related to increasing the SOL scores of the students. Is field trip directly related to increasing the students SOL scores? yes no Purpose of field trip: Number of students: Number of adults: Number of Buses: *NOTE: Passenger limit is 50 per bus. Type of Bus: school bus red & white charter bus bussett lift bus Special requirements/equipment needed: seat belt car seat monitor wheelchair Teachers in charge (list first and last names): Bill to/billing code: APPROVAL SIGNATURES NOTE: All Over 50- Miles/Overnight field trip requests must be forwarded directly to the Chief Academic Officer. Any field trip requests sent directly to the Department of Transportation from the school will be returned without action. Print Name Signature Date School Principal: Chief Academic Officer: Form updated 15 March 2010 page 1 of 6

2 Richmond Public Schools Field Trip Permission Form Name of Activity: Date of Activity: Purpose of Activity: Objective: This trip correlates to the specific Standards of Learning for. Destination: Departure time: Return time: Sponsor(s): Money or Lunch Needed: Method of Transportation: Particular risks or hazards involved in activity, if any: Additional information: Return this permission form to school no later than: (name of activity) Student s name: Homeroom: Yes, my child may participate in the activity described. No, my child may not participate in the above mentioned activity. / / Parent s Signature Date Telephone Number(s) cell-home-work/other Form updated 15 March 2010 page 2 of 6

3 School: Principal: Sponsor(s): Date(s): Richmond Public Schools Out of Town Permission Form Part A: Consent I, as the parent or legal guardian, agree to allow my child,, to travel to to participate in on the following dates:. Person the trip supervisor will contact in case of emergency during the trip: Name: Home phone #: Cell phone #: Work phone #: PART B: DETAILS Departure date: Departure time: Return date: Return time: School employee that the parent/guardian may contact for information during the trip: Name: Phone #: Note: The permission form and the Consent and Indemnification form must be returned to the Principal s office prior to departure. Students who do not turn in these forms will not be allowed to travel on School District sponsored trips. Form updated 15 March 2010 page 3 of 6

4 Indemnification: Richmond Public Schools I, (name of parent/legal guardian,) hereby release Richmond Public Schools, its employees and tour chaperones of any and from all claims, actions, cause of action for loss or injuries suffered or sustained by the said student which may arise out of or during participation in the described trip, and furthermore, do hereby expressly covenant and agree to indemnify against loss from any and all further claims, demands or actions that may hereafter, and at any time, be made or brought against Richmond Public Schools and tour chaperones by myself or anyone on his/her behalf for the purpose of endorsing a further claim for damages or on account of the injuries sustained in consequence of the foresaid activity. I further acknowledge that the accompanying teachers will be acting as chaperones and will not be responsible for any illness affecting the student or any illegal acts committed by the student while on the tour. I further acknowledge that the School District is not insured for loss or damage occasioned by war, riot, terrorism or civil unrest and that the said School District cannot and will not be responsible for any loss or injury sustained by the said student as a result of war, riot, terrorism or civil unrest. I further understand adult supervision will be provided by employees or agents of the School District and my child will be expected to adhere to this supervision and abide by rules governing school trips. (date) (signature of parent or legal guardian) FOREIGN TRAVEL Foreign travel refers to trips taken outside the continental United States. Foreign travel requires prior approval from the Superintendent. In some cases, travel may be restricted to school vacation periods. Richmond Public Schools personnel who organize international trips for Richmond s students shall adhere to guidance given by the school division and the Department of Homeland Security. Prior to all foreign exchange/travel programs, RPS personnel shall inform parents of Travel Warnings, Public Announcements, etc. associated with the proposed destination and its bordering countries. RPS personnel shall also submit this information to the Superintendent s Office. Parent or guardians of students who participate in foreign travel chaperoned by Richmond Public Schools personnel must: o agree to attend all orientation sessions; o agree to sign all forms; o recognize and follow leadership and direction of the chaperone; o be cognizant of the fact that student behavior which in any way is detrimental to the program or cause negative or adverse public relations may result in the participant s immediate return to Richmond at the parent s expense; and o provide a copy of the student s passport and visa (when appropriate). Form updated 15 March 2010 page 4 of 6

Richmond Public Schools Overnight/International Field Trip Medical Release Form School: Date of trip: Staff: Student: Grade: Address/City/Zip Code: Date of birth: Home phone #: Cell phone #:

5 Richmond Public Schools Overnight/International Field Trip Medical Release Form School: Date of trip: Staff: Student: Grade: Address/City/Zip Code: Date of birth: Home phone #: Cell phone #: Parent/Guardian: Address/City/Zip Code: Home phone #: Cell phone #: Emergency contact name and phone: Provider: Contract #: Group #: Medical Insurance Information Primary Physician: Address: Phone #: 1. Does your child take medication? yes no If yes, list type, dosage, and when needed: Note: A completed and signed School Medication Prescriber/Parent Authorization Form is required for each medication (prescription or over-the-counter) to be administered during the field trip. 2. Does your child have any allergies? yes no If yes, please list: Does your child require medication to treat severe allergic reactions to insect stings/bites, food, etc.? yes no Note: If yes, a copy of the emergency plan & the form(s) for related medication(s) authorization forms must accompany this form. 3. Does your child have asthma? yes no Note: If yes, a copy of related medication authorization forms must accompany this form. 4. Date of your child s last Tetanus Booster shot: Authorization to Treat/Administer Medication: I hereby authorize medical or surgical treatment of the student listed above if any emergency should arise. I give permission for decisions to be made by the certified teacher in charge and/or a Richmond Public Schools representative. Parent signature: Date: NOTE: Your signature on this form acknowledges your acceptance of financial responsibility for any medical or dental care your child requires. Form updated 15 March 2010 page 5 of 6

6 ITINERARY School: Date(s) of Trip: Sponsor(s): Name/title of Trip: An itinerary is necessary to keep the activities running smoothly and to avoid forgetting an important part of the trip. Please provide the complete itinerary in the space below. Costs included in the trip: Costs not included in the trip: Completed by: Date: Form updated 15 March 2010 page 6 of 6

CHAMPAIGN COMMUNITY UNIT SCHOOL DISTRICT NO. 4 Champaign, Illinois FIELD TRIP PERMIT

CHAMPAIGN COMMUNITY UNIT SCHOOL DISTRICT NO. 4 Champaign, Illinois FIELD TRIP PERMIT FIELD TRIP PERMIT (School) (Student s Name) (Teacher/Sponsor) (Telephone Number) PARENTS/GUARDIANS: A field trip to is planned for (class or group) on. The trip will begin at a.m./p.m. and return at a.m./p.m.