Form Is-112 - Overnight Field Trip And Activity Bus Request

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Warren County Schools
Note: This form must be submitted to the
Overnight Field Trip and Activity Bus Request
Superintendent on the Monday prior
to the Board meeting for approval.
This form should be typed.
School: ______Grade: _____ Date(s) of Trip: _______
Department/Club: _______________________________________________
340: Northside Elementary 330: Mariam Boyd Elementary
Destination: ____________________________________________________
348: Vaughan Elementary
344: South Warren Elementary
354: WCMS
352: WCHS
City: ______________________________ State: _____________________
360: WECHS
700: WNTHS
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. _________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Expenses to be incurred per student:
Registration: $____________
Hotel/Motel: $ ___________
Transportation: $___________
Food: $ ___________
Other: $_________
Student Cost: $___________
Chaperone Cost: $__________
Medical Treatment Consent Form: Yes ________ No_______
Account Pay 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.
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: ___________________________________________________
Board of Education Approval: _________________________________
Date: ___________________________________________________
# of Buses
Student
Child Seatbelts/ Restraints
Teacher(s) Passengers
Chaperone(s) Passengers
Total Number Passengers
Requested
Passengers
ode of Travel:
Commercial Coach
Other (please specify) _________________________________________________________________________
M
Bus Garage Use Only:
Date Received: ______________________________
Vehicle(s) Approved: _______________________
Bus(es): __________________________________
Signature: ___________________________________________________________ Date Approved: _______________________________________________
Original: Submit To Supt’s Office
_____Transportation
_____School (Once Approved)
IS-112
Revised 02/25/10

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