Prairie Rose School Division

Field Trips and Extended Extra Curricular Trips

  1. School Name
  1. Purpose/Description of Activity
  1. Number of Students/Grades Participating

Grade level: ☐ K ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 ☐ 7 ☐ 8 ☐ 9 ☐ 10 ☐ 11 ☐ 12 ☐ Other

Number of students: ______Number of males: ______Number of females: ______

Number of adults: ______Student/Adult ratio: ______

Students attending/participating:

______

  1. Destination/Host Facility

Name: ______

Contact Info: ______

  1. Activity Details

Proposed departure date & time: ______

Total duration of the trip (days/nights): ______

Anticipated return date & time: ______

Number of school days participants would miss:______

  1. Itinerary

Itinerary attached: ☐ Yes ☐ No

  1. Supervisors/Chaperones

Name / Gender / Cell Phone No. / Medical/First Aid Qualifications
24/7 Emergency Contact Person:
______/ ______/ ______/ ______
Teacher in charge:
______/ ______/ ______/ ______
Additional staff:
______/ ______/ ______/ ______
Additional staff:
______/ ______/ ______/ ______
Additional staff:
______/ ______/ ______/ ______
Volunteers:
______/ ______/ ______/ ______
Volunteers:
______/ ______/ ______/ ______
  1. Hotel Accommodations Arrangements

Hotel name: ______

Hotel contact info: ______

  1. Transportation (check all that apply)

☐ PRSD Bus/Van☐ Private Vehicle☐ Charter Bus☐Rental Van ☐ Commercial Airline

Private Vehicle Information:

Driver name: ______License plate: ______

Driver name: ______License plate: ______

Driver name: ______License plate: ______

Driver name: ______License plate: ______

  1. Expenses

Transportation: ______

Accommodations: ______

Fees/Licenses: ______

Food/Meals: ______

Other: ______

  1. Budget

Fee/student: ______

Additional sources of funding: School budget: ______

Fundraising (specify):______

Other (specify):______

  1. Provision for students/families who may be challenged with financial difficulty:
  1. Supervision Plan

Briefly describe the supervision processes to be used: e.g. large or small group settings; lead/sweep; head counts; buddy system; level of supervision (constant visual, on-site, in the area); other elements of supervision plan as relevant:

______

  1. Safety & Emergency Preparations:

Nearest hospital/medical facility: ______

Phone number of hospital/medical facility: ______

Specific safety provisions for activities involving swimming at hotel:

☐ Facility is providing qualified lifeguard

☐ School is providing qualitied lifeguard(s): ______
Note: A qualified high school student can be permitted to fulfill this role provided that they do not participate in the swimming activity

Name of Teacher in ChargeDateSignature

Name of PrincipalDateSignature

Name of SuperintendentDateSignature