FLORENCE UNIFIED SCHOOL DISTRICT #1
ACTIVITY TRIP REQUEST FORM
Date Submitted:2/25/2014
Section 1: Your Contact Information
Submitted by: Erin Karten
Your School Site: FHS
Your position : Teachers
School Phone Number : 520-866-3560 Extension: 7014
Your Emergency Contact Number: 814-441-7125
Are you designated the trip leader? YES NO
If no, who is the designated trip leader? David Silvas
Phone Number for designated trip leader: 520-705-2152
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: 05/23/14 through 05/25/14
Destination of trip: Disneyland, California
Date of departure: 05/23 Time of departure: 10:15 pm
Date of return: 05/25 Time of return: 11:00 am
Purpose of trip: Disneyland Grad Night
Briefly describe trip activities: Students will attend the Grad Night festivities at Disneyland Park.
Name/Address of Site: Name: Disneyland
Address: 1313 Disneyland Drive
City/State Anaheim , CA Zip Code: 92082
Contact Person at Site (Non-School Personnel): General
Phone Number of Contact Person: 800-232-7980
Means of transportation selected: Private Charter District Provided Buses Parent Provided
In general, describe the route to the destination:Leave Florence, go to the I-10, and travel to Anaheim.
Number of Students Participating: 50 FHS Seniors
Number of Chaperones: 5 chaperones
Estimated total cost of activity trip: $7,300.00
Estimated cost per student participant: $150.00
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?
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?
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?
Principal has reviewed all documents and approved the Activity Trip recommends sending Agenda Item to the Governing Board? YES NO
Name of Principal: Thad Gates
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. David Silvas Position: Teacher Phone Number: 520-705-2152
2. Jerry Link Position: Administrator Phone Number: 520-280-6429
3. Heather Isom Position: Teacher Phone Number: 480-268-4816
4. Michael Gutierrez Position: Security Phone Number: --
5. Janel Verhagen Position: Admin. Assistant Phone Number: 267-280-3242
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