Field Trip Request Form - Creekside Charter School

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Creekside Charter Management
Field Trip Request Form
attach copy of field trip itinerary (including times and activities) and
Please
complete ALL sections of this form before
submitting to the Director for approval. Field Trip Request Forms should be submitted at least two weeks in advance of requested
field trip date.
Teacher Name ______________________________________
Date(s) of trip: _____________________________
Date/Time leaving school: ___________
Date/Time returning to school:
___________
Grade/Course attending: ____________
Transportation: ____________
Destination (include name, address and telephone number):
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Total
cost of trip/activity:
$ ____________
Donation amount requested from family per student:
$ ____________
Alternate proposed funding source to finance balance of trip and ensure all children are included (i.e. fundraiser, parent
donation, PTO):
____________________________________________________________________________________________________________
Student activities/purpose of trip:
____________________________________________________________________________________________________________
Curriculum Standards Addressed:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
What instruction will take place prior to the trip to compliment the trip?
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Copy of Driver’s
Copy of Auto
Driver/Chaperone Name
Fingerprinted
License on file
Insurance Policy
qyes
qno
qyes
qno
qyes
qno
1
qyes
qno
qyes
qno
qyes
qno
2
qyes
qno
qyes
qno
qyes
qno
3
qyes
qno
qyes
qno
qyes
qno
4
qyes
qno
qyes
qno
qyes
qno
5
qyes
qno
qyes
qno
qyes
qno
6
I verify that signed permission slips will be obtained, and copies submitted to the school office, for each student participating in the
trip one week prior to departure, and that all Driver/Chaperones are fingerprinted with a copy of their drivers license and auto
insurance verification on file. The permission slips will contain a signed, witnessed consent executed by the parent, or legal guardian,
of each minor participating in the field trip or excursion, per Civil Code 25.8, authorizing adviser in charge to consent to medical/
dental examination, diagnosis, and treatment of the minor during the activity by a physician, dentist, or surgeon, at the parent's or
legal guardian's expense when in the opinion of the adviser such is advisable in the best interest of the child. (AR6153)
Teacher Signature: ______________________________________
Date: ______________________
Director Approval: ______________________________________
Date: ______________________

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