Los Angeles Unified School District Field Trip Form

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LOS ANGELES UNIFIED SCHOOL DISTRICT
FIELD TRIP FORM
CONTACT PERSON:
DATE OF TRIP:
DESTINATION:
RETURN DATE:
DISTRICT NAME: Los Angeles Unified School District
TIME OF DEPARTURE:
TIME OF RETURN:
SCHOOL:
Please attach list of students to this form. This list and payment must be received in K&K Insurance Group’s
office prior to the date of the Field Trip. All information on this list must be completed before the form will be
accepted. Please provide an email address where processing confirmations can be sent. If the form is received
without payment and list, it will be returned to the school.
PLEASE CHOOSE ONE SET OF RATES BELOW:
HIGH OPTION FIELD TRIP RATES
OVERNIGHT TRIP
$2.00 PER PARTICIPANT FOR 5 NIGHTS & UNDER
ONE WEEK TRIP
$1.00 PER PARTICIPANT PER DAY FOR 5 NIGHTS & OVER
Total Number of Students to be Insured
x $2.00 Per Participant (Overnight Trip 5 Nights or Less) =
__________
Total Number of Students to be Insured
x $1.00 Per Participant (Per Day for Over 5 Nights) =
__________
LOW OPTION FIELD TRIP RATES
OVERNIGHT TRIP
$1.70 PER PARTICIPANT FOR 5 NIGHTS & UNDER
ONE WEEK TRIP
$0.85 PER PARTICIPANT PER DAY FOR 5 NIGHTS & OVER
Total Number of Students to be Insured
x $1.70 Per Participant (Overnight Trip 5 Nights or Less) =
__________
Total Number of Students to be Insured
x $0.85 Per Participant (Per Day for Over 5 Nights) =
__________
Signature of School Official: ________________________________
Date: ____________________
Email Address(es) for Confirmation: _____________________________________________________
METHOD OF PAYMENT:
 Check Attached
MAKE CHECK PAYABLE TO: K&K Insurance Group, Inc.
 Pay by Credit Card:
(Rejection of check or credit card by bank for any reason will invalidate insurance.)
K&K Insurance Group, Inc.
MAIL THIS LIST AND PAYMENT TO THE ATTENTION OF:
th
1945 59
Street N
St Petersburg, FL 33710
If paying by credit card, email to
or fax to 312-381-0682
For Questions, please call Cheryl Norris at 260-459-5885 or 800-441-3994 ext 5885.
FieldTripForm/LAUSD/12

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