Form Is-109 - Field Trip And Activity Bus Request

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Warren County Schools
Note: This form must be submitted for
Field Trip and Activity Bus Request
approval, 10 days prior to the date of trip.
This form should be typed.
School: ______Grade: ______ Date(s) of Trip: ___________
Department/Club: ________________________________________
Destination: _____________________________________________
340: Northside Elementary 330: Mariam Boyd Elementary
348: Vaughan Elementary
344: South Warren
City: ___________________________ State: _________________
354: WCMS
352: WCHS
360: WCECS
700: WCNTS
Departure Date: ___________________
Time: ___________________
Return Date: __________________
Time: ___________
Describe fully the site(s) to be visited and the activities to be engaged in by participants: ____________________________________
_________________________________________________________________________________________________________________
Relate the trip’s activities to the specific portion of the curriculum under study: ____________________________________________
_________________________________________________________________________________________________________________
Account Pay Code for Driver: ________________________________and Expense Code: _____________________________________
Bus Driver(s): ____________________________________________________________________________________________________
I have approved this activity and this request is submitted with full knowledge and understanding of the Warren County Board of
Education policies governing use of activity buses if access is available.
Sponsor’s Signature: _________________________________________
Date: _____________________________________________
As principal I have collected and placed on file a signed copy of the Field Trip and Medical Treatment Consent Form for each
student participation in this trip and confirm that each student attends the Warren County School system. Furthermore, all adults
serving as chaperones are Warren County School employees, parents of students on the field trip, and/or school volunteers.
Principal’s/Director’s Signature: _______________________________
Date: ______________________________________________
Asst. Superintendent’s Signature: ______________________________
Date: _____________________________________________
# of Buses
Student
Child Seatbelts/
Teacher(s) Passengers
Chaperone(s) Passengers
Total # Passengers
Requested
Passengers
Restraints
Bus Garage Use Only:
Date Received: ___________________________
Vehicle(s) Approved: ________________________
Bus(es): ______________________________
Signature: __________________________________________________________ Date Approved: __________________________________________
Original: Submit To Asst. Supt’s Office
_____Transportation
IS-109
_____School (Once Approved)
Revised 02/25/10

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