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