FLORENCE UNIFIED SCHOOL DISTRICT #1
ACTIVITY TRIP REQUEST FORM
Date Submitted:08/27/2013
Section 1: Your Contact Information
Submitted by: John Allee
Your School Site: Florence K-8
Your position : Middle School Science
School Phone Number : 520-866-3540 Extension: 2005
Your Emergency Contact Number: 520-280-3256
Are you designated the trip leader? YES NO
If no, who is the designated trip leader? Erin Lewis
Phone Number for designated trip leader: 520-233-4685
Section 2: Activity Dates/Location/Specific Travel Information
Type of Activity: Out of State Travel In-State Travel (More than 75 miles)
Date(s) of trip: March 13, 2014 through March 15, 2014
Destination of trip: Project Exploration San Diego, CA
Date of departure: March 13, 2013 Time of departure: 10:00 PM
Date of return: March 15, 2013 Time of return: 10:00 PM
Purpose of trip: Science Oceanography Exploration
Briefly describe trip activities: The students will participate in experience lab activities such as: sea life exploration, natural and manmade disasters, plantlife, and the effects it has on the ecosystem. This will also support the sixth grade science standards.
Name/Address of Site: Name: Project Exploration
Address: 1647 S. Blue Island
City/State Chicago, IL Zip Code: 60608
Contact Person at Site (Non-School Personnel): Jenny Stephan
Phone Number of Contact Person: 773-307-4419
Means of transportation selected: Private Charter District Provided Buses Parent Provided
In general, describe the route to the destination: Students and chaperones will travel via motorcoach from Florence, AZ to San Diego, CA.
Number of Students Participating: 50
Number of Chaperones: 3
Estimated total cost of activity trip: $352
Estimated cost per student participant: $17,600
Section 3: Parent Permission Slips/Emergency Medical Release Forms
Permission slips/medical release forms have been collected from all students?
YES NO
If NO, who is responsible to collect these documents prior to departure?
The trip sponsors will collect all permission slips from students going on the trip.
Trip leader has copies of parent permission/medical release forms that will be accessible during the trip? YES NO
If NO, who is responsible for making these copies?
The trip sponors is responsible for making copies of the permission slips.
Copies of the parent permission/medical release forms have been left at the school site office? YES NO
If NO, who is responsible for making copies for the office?
The trip sponors is responsible for making copies of the permission slips.
Principal has reviewed all documents and approved the Activity Trip recommends sending Agenda Item to the Governing Board? YES NO
Name of Principal: John Allee
Will Requestor be present at Governing Board Meeting to respond to questions? YES NO
Please provide any other pertinent information:
Section 4: Chaperones/Contact Phone Numbers
List of Chaperones and Phone Numbers:
1. Erin Lewis Position: 6th Grade Science Teacher Phone Number: 520-233-4685
2. Michelle Fogarty Position: 6th Grade Resource Teacher Phone Number: 520-510-8130
3. Position: Phone Number: --
4. Position: Phone Number: --
5. Position: Phone Number: --
6. Position: Phone Number: --
7. Position: Phone Number: --
8. Position: Phone Number: --
Section 5: Activity Trip Exposure Analysis Checklist
Is the location of the activity indoors or outdoors? Indoors Outdoors Both
Are special clothing needs such as shoes, jackets, or gloves required? Yes No
Does the trip location include exposure to insect or animal bits, falling rocks, puncture wounds from plants, or eye irritation from dust or other airborne particles? Yes No
Does the trip require climbing above or below the ground floor? Yes No
If yes, are walkways well marked? Yes No N/A
Do they include hand or guardrails? Yes No N/A
Are they maintained in good condition? Yes No N/A
Have extraordinary exposures been included on the Activity Trip Permission Form to provide an informed consent from parent or guardian? Yes No N/A
Are first aid services available at the trip location in the event of an injury or illness?
Yes No
Are food and water available at the trip location? Yes No
If not, will the students bring their own food and water? Yes No N/A
Are facilities available to safely store food and water? Yes No N/A
Has the travel route been planned in advance? Yes No
Will transportation make stops traveling to or from the trip location? Yes No
If yes, have stops been planned to maintain student control and safety? Yes No N/A
Is adequate parking available for safe vehicle loading, unloading, parking, and turn around? Yes No
Does the learning experience involve direct contact with plants or animals? Yes No
If yes, have students been questioned about potential allergic reaction? Yes No N/A
Is prior evidence of liability insurance protection required by the trip location owner to allow use of the facility or property? Yes No N/A
If trip includes residence at a camp facility, does the owner require proof of student accident insurance? Yes No N/A
If the trip includes a wilderness program, have special arrangements been made for emergency or medical evacuation? Yes No N/A