Leuzinger High School

/ Leuzinger High School
4118 W. Rosecrans Avenue, Lawndale, California 90260
Home of the Olympians

FIELD TRIP PACKET 2017-2018

Field trips can be a positive supplement to the academic program. Below are the procedures required for each field trip to ensure the safety of students and staff members.

ALL field trips must be approved and calendared by school administration. This includes trips that take place after school hours and/or on non-school days.

Procedures:

1. Read and complete the Field Trip Packet. This packet includes:

• Field Trip Expectations & Responsibilities for Teachers & Students
• Field Trip Request Form
• Educational Value Statement
• Field Trip Attendance Roster
• Parent Permission & Emergency Information Form
• CVUHSD Wavier Agreement Form
• Medical Release Form
• Trips Requiring Board Approval Information
• Board Agenda Analysis Forms

Submit the completed Field Trip Information Package with purchase requisition form for bus transportation (if applicable) and Board Agenda Analysis (if applicable) to Dr. Ho Rm. 112, ext. 2303.

*Dr. BrownHas Final Approval On All Field Trips*

NO FIELD TRIPS ALLOWED DURING AP & SBAC TESTING!

1. One week prior to the field trip submit a list of students to Dr. Ho, Rm. 112, ext. 2303andverify that these students are not on the *NO GO LIST*.
2. Notification of final approval of the field trip will be placed in your box immediately following approval.
3. Every student participant must have a parent permission card, off-campus permit card, and medical release form signed a week prior to the field trip date.
4. Submit a list of students who participated in the field trip no later than 8:00am on the school day immediately following the trip (including weekend field trips) to the Attendance Office.
5. Place a copy of the list of students who attended the field trip in teachers’ mailboxes the day following the fieldtrip.

LEUZINGER HIGH SCHOOL

FIELD TRIP EXPECTATIONS AND RESPONSIBILITIES

Student Rules and Expectations

1. Adhere to the Olympian Code of Conduct even when away from the school site.

1. Submit Parent Permission for Excursion card and Medical Release Form signed by parent/guardian to the field trip sponsor.

1. Submit Off-Campus Permit card signed by teachers of classes that will not be attended as a result of field trip participation to the field trip sponsor.

1. Complete in a timely manner all assignments missed as a result of attending the field trip.

Teacher Responsibilitiesand Expectations

1. If you are planning to transport students in your car or a district vehicle at any time during the 2017-2018 school year, you will need to be approved as an authorized driver by your Principal and by Dwayne Eatmon III, Director of Security on x4457 by completing the *Authorization to Transport Students* Form. Forms are available in the Main Office.

1. Call Sub-Finder and contact the principal’s secretary for substitute coverage if needed.
2. Provide detailed lesson plans and seating charts for your classes that will need substitutecoverage.
3. Verify that students attending field trip are not on the no-go list.
4. Distribute forms to students immediately after receiving approval signatures.
5. Contact Jennifer Le at the district office to confirm that a bus has been secured.
6. Submit confirmed field trip attendance list to Liz Contreras 2 days before the trip.
7. Verify that all students have signed permission forms and emergency information prior to leaving campus.
8. Keep student emergency information and medical release forms accessible during the entire field trip.
9. Take accurate attendance during the field trip.
10. Use the Field Trip Attendance List to submit names and ID numbers for all students who attended the field trip. Submit copies to the Attendance Office no later than 8:00am on the school day immediately following the field trip.
11. Place a copy of the list of students who attended the field trip in teachers’ mailboxes the day following the fieldtrip.

LEUZINGER HIGH SCHOOL

FIELD TRIP REQUEST FOR APPROVAL

Requests must be submitted to Dr. Ho a minimum of 1 month prior to the trip.

Field trips that travel overnight or include water sports/boat travel require 2 MONTHSadvance notice and CVUHSD Board Approval.

Organization/Class: ______

Field Trip Destination: ______

Address: ______City: ______Zip: ______

Name and Title of Contact at the Field Trip Destination: ______

Destination Contact Phone Number: ______

Date of Departure: ______Date of Return:  same day  other ______

Departure Time: ______Return Time: ______

Sponsor’s Name ______Cell # ( )

Meet-up Location (be specific): ______Field Trip Meet-up Time:______

Grade level of students attending trip: ______# of students attending trip (approx.) _____

Sponsors are required at a ratio of one sponsor per 12 students. If additional sponsors are needed, please indicate names and positions (teacher, instructional aide, parent, etc.).

Name: ______Position: ______

Name: ______Position: ______

Name: ______Position: ______

EXPENSES:

• Transportation (check one): 52-seat bus  48-seat bus 12-seat van

*other ______

• * If planning to transport students in private vehicles or van, each driver must have an approved CVUHSD Authorization to Transport Students on file or submit one with all required documentation at least four weeks in advance for approval. The form is included in this packet.

• Funding source for transportation: ______

• Ticket or admission charges: ______Funding source: ______

• Other expenses (please explain and include funding source): ______

I have read and fully understand the field trip policies and procedures. I acknowledge that this field trip cannot be approved without an Educational Value Statement and that I must submit the Field Trip Attendance Listno later than 8:00am on the school day immediately following the field trip.

Sponsor’s Signature: ______Date: ______

Approvals: ______Howard Ho (AP) Pamela Brown (Principal)

LEUZINGER HIGH SCHOOL

FIELD TRIP EDUCATIONAL VALUE STATEMENT

Please provide short statements as evidence that this trip has educational value, supports course learning standards and justifies students missing other classes.

• What is the academic purpose of this field trip?

• What learning standard(s) or ESLR(s) is/are addressed by this field trip?

• How will you connect this field trip to content and skills students need to master in your class?

• What activities will students be expected to complete prior to, during, and/or after the trip?

• How will this field trip help students in making college/career decisions?

YOUR TRIP WILL NOT BE APPROVED WITHOUT THIS VALUE STATEMENT!

LEUZINGER HIGH SCHOOL

Field TripConfirmed Attendance List

This form must be submitted to Liz Contreras in the main office at least 48 hours before the trip.

Date of Trip:______Program/Academy: ______

Destination:______Number of Subs requested: ______

Name (Last, First) / ID# / Name (Last, First) / ID#
1. / 26.
2. / 27.
3. / 28.
4. / 29.
5. / 30.
6. / 31.
7. / 32.
8. / 33.
9. / 34.
10. / 35.
11. / 36.
12. / 37.
13. / 38.
14. / 39.
15. / 40.
16. / 41.
17. / 42.
18. / 43.
19. / 44.
20. / 45.
21. / 46.
22. / 47.
23. / 48.
24. / 49.
25. / 50.

Sponsor’s Name: ______

Sponsor’s Signature: ______Date: ______

LEUZINGER HIGH SCHOOL

FIELD TRIP ATTENDANCE LIST

This form is due to the Attendance no later than 8:00am on the school day

immediately following the field trip.

These students submitted all required forms and attended a school-approved field trip on:

______/_____/______

Day of the week Month Date Year Time/Period

Destination:______Sponsor______

Name (Last, First) / ID# / Name (Last, First) / ID#
1. / 26.
2. / 27.
3. / 28.
4. / 29.
5. / 30.
6. / 31.
7. / 32.
8. / 33.
9. / 34.
10. / 35.
1. / 36.
12. / 37.
13. / 38.
14. / 39.
15. / 40.
16. / 41.
17. / 42.
18. / 43.
19. / 44.
20. / 45.
21. / 46.
22. / 47.
23. / 48.
24. / 49.
25. / 50.

______

Sponsor SignatureDate

LEUZINGER HIGH SCHOOL

SACK LUNCHES FOR FIELD TRIP

Please fill out this form ONLY if you need the school to provide sack lunches for your students.

This form is due to Vickie Laney () in Food Services at least 5 days prior to the trip.

______/_____/______

Day of the week Month Date Year Time/Period

Destination:______Sponsor______

Name (Last, First) / ID# / Name (Last, First) / ID#
1. / 26.
2. / 27.
3. / 28.
4. / 29.
5. / 30.
6. / 31.
7. / 32.
8. / 33.
9. / 34.
10. / 35.
1. / 36.
12. / 37.
13. / 38.
14. / 39.
15. / 40.
16. / 41.
17. / 42.
18. / 43.
19. / 44.
20. / 45.
21. / 46.
22. / 47.
23. / 48.
24. / 49.
25. / 50.

______

Sponsor SignatureDate

FIELD TRIP PERMISSION & EMERGENCY FORM

All students attending an approved field trip must submit the following forms to the trip sponsor.

1. Field Trip Permission & Emergency Form (this form)
2. Medical Release Form

These forms must be accessible to the sponsor during the entire field trip.

Centinela Valley Union High School District

WAIVER, RELEASE AND INDEMNITY AGREEMENT

ASSUMPTION OF RISK FOR PARTICIPATION

IN VOLUNTARY ACTIVITY

Student’s Name: ______School:LEUZINGER HIGH SCHOOL

Description of Activity: ______

Date(s) of Activity: ______

By my signature below, I hereby give permission for my son/daughter to participate in the above described activity. I realize that this activity is voluntary and is not a mandated requirement of the Centinela Valley Union High School District curricular or extra-curricular program. The undersigned is specifically aware and confirms by executing this document that they are aware that participation in such an activity presents a risk of personal injury, bodily injury, property damage or wrongful death, and that the undersigned’s child may injure himself or herself, or be injured by other participants related to the activity. The undersigned is specifically aware and acknowledges being aware of the risk that he or she may be hurt or injured by participating in any aspect of this activity.

For and in consideration of permitting the above named child to participate in the activity described above, the undersigned hereby voluntarily releases, discharges, waives and relinquishes any and all actions or causes of action for personal injury, bodily injury, property damage or wrongful death occurring to him/herself arising in any way whatsoever as a result of engaging in said activity or any activities incidental thereto wherever or however the same may occur and for whatever period said activities may continue. The undersigned does for him/herself, his/her heirs, executors, administrators and assigns hereby release, waive discharge and relinquish any action or causes of action, aforesaid, which may hereafter arise for him/herself and for his/her estate, and agrees that under no circumstances will he/she or his/her heirs, executors, administrators and assigns prosecute, present any claim for personal injury, bodily injury, property damage or wrongful death against the District, its Board, or any of its officers, agents, servants, or employees for any of said causes of action. The foregoing waiver does not apply in the event of the sole negligence or willful misconduct of the District.

The undersigned hereby acknowledges that he/she knowingly and voluntarily assumes all risks of bodily injury to his/her child, as states, and expressly acknowledges their intention, by executing this instrument, to exempt and relieve the District, its Board, officers, agents, and employees, from any liability for personal injury, bodily injury, property damage or wrongful death that may arise out of or in any way be connected with the above-described activity. I have read the foregoing and have voluntarily signed this agreement. I am aware of the potential risks involved in this activity and I am fully aware of the legal consequences of signing this instrument.

______

Parent/Guardian Signature Date Student’s Signature Date

______

Parent/Guardian Name (Please Print) Student’s Name (Please Print)

______

Street Address City State Zip

______

Home Telephone Number Work Telephone Number

Centinela Valley Union high SCHOOL district

STUDENT PARTICIPATION IN DISTRICT-SPONSORED VOLUNTARY FIELD TRIP

PARENTAL PERMISSION, ASSUMPTION OF RISK, AND

MEDICAL TREATMENT AUTHORIZATION

Date ______

Student's Name: ______has permission to participate in the following field trip:

Destination/Nature of Activity______

(Please be specific, e.g., Concert at UCLA.)

Special Instructions:______

(e.g., Bring sack lunch.)

Departure Return

Date: ______Time: ______Date: ______Time: ______

Person in Charge: ______Position:______School: ______

Type of Transportation: District Bus/VehicleWalkingOther:______

Health or special needs:Check as appropriate.

My student has no special health needs the staff should be aware of, and no medication is required on the trip.
My student has a special need, and instructions are attached. Number of attached pages:______.
Other:

In the event of illness or injury, I do hereby consent to whatever x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care and emergency transportation considered necessary in the best judgment of the attending physician, surgeon, or dentist and performed under the supervision of a member of the medical staff of the hospital or facility furnishing medical or dental services.

I fully understand that participants are to abide by all rules and regulations governing conduct during the trip.

As provided for in California Education Code Section 35330, I agree to waive all claims against the Centinela Valley Union High School District (District) and hold the District, its officers, agents and employees, harmless from any and all liability or claims, which may arise out of or in connection with my child's participation in this activity. This waiver shall not apply to any occurrences which may arise solely out of the negligence of the District, its employees or agents.

______Work Phone ( )______

Signature (Parent/Guardian) (Please Print Name)

Home Phone ( ) ______

______Student’s Date of Birth Student’s Signature

Family Medical

InsuranceCarrier (REQUIRED):______Policy Number (REQUIRED):______

(e.g., Blue Cross)

In the event of an emergency, please contact:

______Work ( ) ______

(Name) (Relationship)

Home ( ) ______

Distrito escolar Centinela Valley Union High school district

participaciÓn estudiantil en excursiÓn escolar voluntaria patrocinada por el distrito

permiso de los padres, asunciÓn de riesgo y

autorizaciÓn para administrar tratamiento mÉdico

Fecha______

Nombre del estudiante: ______tiene permiso para participar en la siguiente excursión escolar:

Destino/Índole de la actividad______

(Favor de especificar, ej., concierto en UCLA.)

Instrucciones especiales: ______

(ej., traer almuerzo de casa.)

Salida Regreso

Fecha: ______Hora: ______Fecha: ______Hora: ______

Persona a cargo: ______Puesto:______Escuela: ______

Tipo de transporte: Vehículo/Autobús del distrito A pie Otro:______

Salud o necesidades especiales: Favor de marcar donde corresponda.

Mi estudiante no tiene necesidades especiales de salud de las que el personal ha de tomar en cuenta y no seránecesario administrar medicamentos durante la excursión.
Mi estudiante tiene una necesidad especial; se adjuntan instrucciones. Número de páginas adjuntas:______.
Otro:

En caso de enfermedad o lesión, por medio de la presente consiento a todo examen de rayos-x, anestesia, diagnosis o tratamiento médico, quirúrgico o dental, al igual que atención hospitalaria y transporte de emergencia que se considere necesario según el mejor criterio del médico, cirujano o dentista encargado y que se practique bajo la supervisión de un integrante del personal médico del hospital o instalación que administre los servicios médicos o dentales.

Plenamente entiendo que los participantes han de cumplir con todas las reglas y reglamentos que regulen la conducta durante la excursión.

Según lo dispuesto en la Sección 35330 del Código de Educación de California, acuerdo renunciar todo reclamo contra Centinela Valley Union High SchoolDistrict (Distrito) y de eximir al Distrito, sus funcionarios, agentes y empleados de cualquier y toda responsabilidad o reclamo que pueda surgir de o en conexión con la participación de mi hijo(a) en esta actividad. Esta renuncia no le corresponde a un incidente que pueda surgir únicamente a razón de la negligencia del Distrito, sus empleados o agentes.

______Teléfono del trabajo ( )______

Firma (padre/madre/guardián) (Favor de escribir el nombre en letra de molde)

Teléfono del hogar ( ) ______

______

Fecha de nacimiento del estudiante Firma del estudiante

Compañía de seguro
médico familiar:______Número de póliza:______

(ej., Blue Cross)

En caso de emergencia, favor de comunicarse con:

______Trabajo ( ) ______

(Nombre) (Vínculo)

Hogar ( ) ______

CENTINELA VALLEYUNIONHIGH SCHOOL DISTRICT

PURCHASE REQUISITION

PrintRequestor Name: Department:

Date: Phone Number:

Adult Ed. District Office hawthorne Lawndale Leuzinger lloyde other

Suggested vendor information / For purchasing only
NAME / QUOTE NO PURCHASE ORDER NO
ADDRESS / TERMS FOB VENDOR NO
CITY STATE ZIP / APPROVED BY DATE
ATTENTION VENDOR PHONE / CONF. PHONE ORDER ON TO BY
QUOTE DATE VENDOR FAX / DELIVERY REQUIRED/ PROMISED
item / Qty. / unit / description / Unit price / Total price
Field Trip Date:
Pick-up Location:
Destination:
Address:
Pick-up Time:
Return Time:
Additional Information (optional):
SUB
TOTAL
SALES
TAX
SHIPPING
TOTAL
ESTIMATED
COST

APPROVALS

Dept. head ______superintendent______

Principal ______inst. Services ______

Business services ______other Approvals ______

LEUZINGER HIGH SCHOOL

FIELD TRIPS REQUIRING BOARD OF EDUCATION APPROVAL

Board of Education approval is required for field trips that involve:

• Overnight stays
• Out of LA County or out of CA State travel
• Bodies of water (boat rides or activities in or near lakes, rivers, pools, and oceans, including trips to the beach)

Field trip requests that require Board approval must be submitted a minimum of 8 weeks in advance.

To have your field trip proposal added to a Board of Education meeting agenda, you will need to:

1. Write a detailed Board Agenda Analysis.
2. Follow the format in the sample on the next page.
3. Be sure to include details about the proposed trip, including the trip’s purpose, value to CVUHSD students and educational programs, and specifics about travel arrangements, supervision, and associated expenses.

1. Submit the Board Agenda Analysis with your field trip request packet.
2. Once the field trip is approved at the building level, the field trip proposal, along with the Board Agenda Analysis, will be sent to Educational Services to be approved by the Assistant Superintendent for Educational Services. Once approved at that level, that office will forward the analysis to the superintendent’s office for Board approval. The Superintendent’s office will submit it to be added to the agenda of the next Board of Education meeting.

1. Follow-up.
2. Check with the Superintendent’s office the day after the scheduled Board meeting to find out if your field trip was approved. The principal’s secretary can help you make that contact. Once you know the trip has been approved, you may plan the trip.

BOARD AGENDA ANALYSIS

TITLE:APPROVAL OF OVERNIGHT TRIP FOR LEUZINGER HIGH SCHOOL’S

(ADD YOUR OWN GROUP NAME AND TITLE OF REQUESTED EXCURSION)

PERSON(S) RESPONSIBLE:

Dr. Pamela Brown, Principal Leuzinger High School

Dr. Kelly Santos, Assistant Superintendent, Educational Services

__X__ ACTION

_____ INFORMATION

BACKGROUND INFORMATION

(ADD YOUR DETAILED DESCRIPTION OF YOUR PROPOSED EXCURSION, INCLUDING BACKGROUND INFORMATION, JUSTIFICATION FOR IT FROM AN EDUCATIOAL STANDPOINT, DETAILS OF THE FIELD TRIP PROGRAM AND HOW IT TIES TO THE STANDARDS)

COST IMPLICATION

(ADD DETAILS ABOUT ALL ASSOCIATED EXPENSESie. Sub- cost, admissions, bus)

FUNDING

Indicate account string

ADD DETAILS ABOUT HOW ALL ASSOCIATED EXPENSES WILL BE PAID

RECOMMENDATION

Approve/Ratify the (TRIP TYPE) fieldtrip for Leuzinger High School’s (NAME OF CLASS OR PROGRAM) class to (LOCATION), ON (DATES), funded by (LIST FUNDING SOURCE).

Approved for presentation to the Governing Board: (ADD THE DATE OF THE BOARD NEXT MEETING--AGENDA ITEMS MUST BE SUBMITTED AT LEAST 8 WEEKS IN ADVANCE)

______

Dr. Gregory O’Brien,Superintendent

Secretary to the Board