Field Trip Forms And Procedures - ESUHSD

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EAST SIDE UNION HIGH SCHOOL DISTRICTInstructional Services DivisionJulianna Arreola – Administrative Secretary Phone: 347-5061 FAX: 347-5065Email: [email protected] Trip Forms and ProceduresStudent Activity Field Trip Request Form Front of form completed (Purpose of Trip and Relevance must have a specific description; Destination – Please specify cityand state) Account numbers noted (The Board would like to know what budget, if any, will be impacted.) Signed by teacher. Administrator must also sign and date. Please submit the original and updated version of request form(s) Request form for trips out of the country should be submitted no later than 2 months prior to contemplated departure date. Local field trips that are not overnight, do not need district approval. Please make sure that the Supervisors attendingare certificated East Side staff.NOTE: Per federal regulations, bag lunches must be offered to all students for trips during the school day.Contact site kitchen manager at least one week in advance.Student Activity Field Trip Request Form (Page 2 of 2) (Page 2 of 2) should be checked off where applicableList of Students List of students with ID number (This applies to ALL field trips)Field Trip Authorization and Release Form * Completed by each student for every field trip and kept on file at siteSchool Bus Request (New forms are available on the web) Original or copy of bus request (Site responsible for calling transportation to secure bus.)Personal Automobile Use Form must be completed by each driver for each field trip (original – district office; copy – site) Form must be signed by site principal Must include copy of driver’s license Must include copy of proof of auto insuranceTransportation Authorization To be completed by each student riding as a passenger in a vehicle driven by an adult. (original – district office; copy – site)Chartered Bus and Other Rented Vehicle(s) Copy of Invoice Current insurance certificate of company NOTE: Before you contract a chartered bus company, you must first contact the District transportation department usingthe new bus request form. If transportation cannot accommodate you, they will check off the appropriate box. A copy ofthe form indicating their unavailability must accompany your field trip packet.Request for Purchase Order For cost of chartered bus, rented vehicle(s), admissions fee, etc.Air Travel Itinerary from air lines Must purchase traveler’s insurance (with ticket or separately)Itinerary of Events For all trips out-of-country, out-of-state, overnight or over 60 miles Accommodation arrangements for overnight tripsParent/Guardian Permission for Student Participation in Off-Campus School Sponsored Events To be completed by each student for out-of-state and out-of-country events Original – district office; copy - siteBOARD APPROVAL NEEDED FOR TRIPS THAT ARE: Over 60 miles Overnight Out-of-state Out-of-country*Available in Spanish and VietnameseRev. 08/24/17 JA

OVERNIGHT TRIPS AND TRIPS INVOLVING AIR TRAVEL MUST BE RECEIVED BY THE DISTRICT OFFICEAT LEAST EIGHT WEEKS PRIOR TO REQUESTED DATEEAST SIDE UNION HIGH SCHOOL DISTRICTSTUDENT ACTIVITY FIELD TRIP REQUEST FORMFOLLOW INSTRUCTIONS ON BACK OF THIS FORMToday’s Date: School: Group:Student Preparation:Destination of Trip:(City and State)Date Leaving: Time:(special instructions, funds, clothing, special equipment or training, release form, etc.)Date Returning: Time:Potential Hazards & Appropriate Contingency (if necessary):Purpose of Trip:(ie., college visit, educational trip, student conferences, field study)Number of Students Attending: Number of Supervisors:How expenses (if any) will be raised:Name of Supervisors:Cost to Pupils: How Paid:Transportation Needs:Provisions for students who cannot afford to come up with funds on their(ie., chartered bus, personal private vehicle, public transportation, school bus, air travel, etc.)own (if applicable)Insurance Needs:PLEASE CALL TRANSPORTATION TO RESERVE DISTRICT BUS(ES). ATTACH BUS REQUEST IF DISTRICT IS PROVIDING TRANSPORTATION.Charge Account Number: / / / / / / / /Number of Subs Required:Period(s) / / / / / /Charge Account Number: / / / / / / / /Relevance of this field trip to current unit of study/program goals:LESSON OBJECTIVES OF TRIPACTIVITIESSchool Approvals:Signature (Teacher Initiating Request)Teacher Extension #MEASUREMENT OF LESSON OBJECTIVESDistrict Approval:*Principal/Site AdministratorSuperintendent/District DesigneePage 1 of 2* My signature assures that every student going on this field trip has completed and returned a Field Trip Authorization & Release form.Rev-JA 7.16.18

LOCAL FIELD TRIPSOUT OF STATE/BEYOND 60 MILESThe following items must be checked off as completed PRIOR tosubmitting field trip request for principal and/or APED approval forlocal field trips.The following items must be checked off as completed PRIOR tosubmitting field trip request for Superintendent/Board approval.1. Educational Trip (relevance to current unit ofstudy)2. Transportation NeedsSchool Bus (must have bus request and/orcopy for submittal to transportation)Personal Private Vehicle (must submitPersonal Automobile Insurance verification withfield trip request)Chartered and/or rented vehiclesMust submit a current insurance certificate and anendorsement of additional covered interest namingESUHSD as additional insured attached to the fieldtrip request. If renting a van with 10 (or more)passengers, including driver, designated driver musthave a Class A driver’s license.3. Cost to Students (no student will be excluded froma field trip because of lack of funds)Provisions have been made for those studentswho cannot afford to come up with funds of theirown.4. Must have Principal/APED approval1. Educational Trip (relevance to current unit ofstudy)2. Transportation NeedsSchool Bus (must have bus request and/orcopy attached for submittal to transportation)Personal Private Vehicle (must submitPersonal Automobile Insurance verification withfield trip request)Chartered and/or rented vehiclesMust submit a current insurance certificate and anendorsement of additional covered interest namingESUHSD as additional insured attached to the fieldtrip request). If renting a van with 10 (or more)passengers, including driver, designated driver musthave a Class A driver’s license.Air Travel (must submit an itineraryattached to the field trip request)3. Cost to Students (no student will be excluded froma field trip because of lack of funds)Provisions have been made for those studentswho cannot afford to come up with funds on theirown.4. Itinerary of Events (for all trips out of state,overnight and beyond 60 miles)5. Must have Principal/APED approvalPage 2 of 2

East Side Union High School DistrictDepartment of Insurance and Risk Management830 North Capitol AvenueSan Jose, CA 95133(408) 347-5061FIELD TRIP AUTHORIZATION & RELEASEDear Parent/Guardian:Student Name: Age:Address: City: Zip: Phone:has my permission to participate in the activity shown below.Date:Meeting Place:Time of Departure:Time Returning:Transportation Provided By:School Transportation:YesNoVoluntary Drivers:YesNoI am aware that during any trip or excursion injury or death may occur from hazards, including but not limited to,hazards of accidents or illness in places without medical facilities, hazards created by the forces of nature, andhazards of travel by air, train, bus, automobile and walking. I am voluntarily permitting my Student to participatein the above activity with the knowledge of the hazards involved and I agree to accept any and all risks of injury ordeath.Parent/Guardian please initial here:In consideration of Student’s participation in the activity described above, I agree that I, my heirs, spouse,guardians, legal representatives and assigns will not make a claim against, or sue East Side Union High SchoolDistrict, its officers, agents or employees for injury, death or property damages arising from the negligence oracts by the East Side Union High School District, its officers, agents or employees, as a result of Student’sparticipation in the activity described above.In addition, I release and discharge the East Side Union High School District, its officers, agents and employeesfrom all actions, claims, or demands that I, my heirs, guardians, legal representatives or assigns now have or maylater have for injury, death or property damage resulting from Student’s participation in the activity described above.This Agreement and Release of Liability are intended to be binding upon heirs, guardians, legalrepresentatives and assigns.I, (Parent/Guardian), HAVE CAREFULLY READ THISDOCUMENT AND FULLY UNDERSTAND ITS CONTENTS. I HAVE EXPLAINED THIS DOCUMENTTO MY CHILD/WARD AND REPRESENT THAT MY CHILD/WARD UNDERSTANDS THECONTENTS OF THIS DOCUMENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY ANDI SIGN IT VOLUNTARILY.Parent/Guardian’s SignatureForm #3002-08 (revised – 8/4/15)dvDatePage 1

If Student is under the age of 18:Name of Parent/Legal Guardian:Parent/Legal Guardian’s Address:Parent/Legal Guardian’s Home Telephone No.:Work:MEDICAL AUTHORIZATION- The undersigned representing him/herself, or on behalf of the child namedabove, hereby authorizes an agent of the EAST SIDE UNION HIGH SCHOOL DISTRICT to consent to anymedical, dental, surgical, or hospital care, treatment or diagnosis for the above named child, under the care orsupervision of any licensed physician, surgeon or dentist. If given on behalf of child, this authorization shall bedeemed given under California Family Code Section 6910. I further agree to pay for any medical, dental, surgical,or hospital care, treatment, or diagnosis provided the above named child pursuant to this authorization, and todefend, indemnify and hold harmless East Side Union High School District from any actions, claims, or demandsthat I, my heirs, guardians, legal representatives or assigns, or any other person or entity may now have or may laterhave, including but not limited to claims for injury, death, property damage, or medical bills and expenses resultingfrom care, treatment, or diagnosis provided to the above named child pursuant to this authorization.Student’s Physician:Physician’s Address: Telephone No.:Medical Insurance: Group Number:Subscriber’s Name: ID Number:Employer’s Address:CANCELLATION NOTIFICATION – I am aware that in the event the field trip is cancelled the East Side UnionHigh School District will not be responsible for reimbursing any costs/expenses incurred.Parent/Guardian please initial here:Parent/Guardian of StudentDateParent/Guardian of StudentDatePlease list any allergies or special medical conditions of Student:TEACHER ACKNOWLEDGEMENT:Per.Class1234567Form #3002-08 (revised – 8/4/15)dvSignature and DatePage 2

EAST SIDE UNION HIGH SCHOOL DISTRICTPARENT/GUARDIAN PERMISSION FOR STUDENTPARTICIPATION IN OFF-CAMPUSSCHOOL-SPONSORED EVENTShas my permission to attend(NAME OF STUDENT)which will take place at:(ACTIVITY/EVENT)Date of event: Class or group attending:Teacher or leader:Method of Transportation:If traveling by automobile, name of driver:1.I understand that all students going on this trip will be responsible in conduct to the busdriver, to teachers or adult sponsors. It is further understood that students will go andreturn from the event on the transportation provided and that every reasonable cautionwill be maintained on the trip.2.I hereby acknowledge that I have been advised that the activities involved in thisexcursion/field trip are are not considered by the District to be of “highrisk” to the participants.(DATE)(PARENT OR GUARDIAN SIGNATURE)WAIVER OF CLAIM(To be completed for Out-of-State or Out-of Country events only)In granting permission to attend, I do hereby waive all claims and hold harmless the individualsponsors, the East Side Union High School District, and the State of California for any injury,accident, illness, death, or any loss or damage to personal property occurring during or by reasonof this excursion/field trip or event.(DATE)Rev 2/04(PARENT OR GUARDIAN SIGNATURE)

BUS REQUESTEast Side Union High School District830 North Capitol Ave.San Jose, California 95133Telephone (408) 347-5292 Fax (408) 347-5295Date of Application:Dept/District:School:# Pass:Date(s) of Use:Requested by:# Buses: Time Leaving School:Pick up atSpecial Instructions:Return Time atFAX #:Destination:Purpose of Trip:Quote:Method ofPayment:(check box)ESUHSD Account #: School Bank #:PO # and Bill to Address required:Other:Approved:Per busApproved:(Administrator authorized to expend funds)(Principal)Approved:(Transportation)ESUHSD Bus not available. Contact Purchasing at (408) 347-5071 for approved vendor list.*Superintendent Approval:*Board Approval:* Required for overnight, out-of-state, and trips over sixty (60) miles.** For Transportation Department only **Vehicle(s):No. of Passengers:Total Miles:Regular:Total Hours:Overtime:Cost @:/Mile Other:District use only:Total Cost Date Received:Distribution: White: Transportation, Yellow: Transportation, Pink: RequesterCost: /Hr.Reg: /Hr.OT: Invoice #:mk 7/05 Form #3000-53

EAST SIDE UNION HIGH SCHOOL DISRICTTRANSPORTATION AUTHORIZATION(Vehicle driven by self and/or another adult person)The undersigned hereby acknowledges and understands that East Side Union HighSchool District is not providing transportation to voluntary school-sponsored activitiesand that it is the responsibility of the undersigned to arrange transportation for his/herson or daughter.As parent/legal guardian, I hereby authorize and give permission for myson/daughter , to provide his/her owntransportation in a self-driven vehicle and/or to ride as a passenger in a vehicledriven by another adult.The undersigned acknowledges and understands the driver is not driving on behalf of, oras an agent of the District. Further, the undersigned understands the District has notverified the driving record of the driver or the mechanical condition of the vehicle.It is fully understood that the District is in no way responsible, nor does the Districtassume liability for any injuries or losses resulting from this non-District sponsoredtransportation. Although the East Side Union High School District may recommendtravel time, routes, or assist in coordinating the transportation to or from this event, Ifully understand that such recommendations are not mandatory.I, the undersigned, further understand that under certain circumstances, the District mayoccasionally provide District sponsored transportation to an event but not necessarilyreturn transportation from the event. Should this transportation be offered, it is strictlyvoluntary.Parents/Legal Guardian SignatureDateParents/Legal Guardian SignatureDate

East Side Union High School DistrictPERSONAL AUTOMOBILE USEPermission FormName Birth dateDriver’s License #Year & Make of AutoVehicle License Plate #Insurance Carrier/AgentPolicy # Expiration DateLiability LimitsDriving RestrictionsI certify the above information is correct and the insurance coverage is in force. Iunderstand I must have liability insurance coverage and agree to advise the District, in writing, ofany changes in the above information.SignatureDatePrincipal’s Signature REQUIREDSignatureNOTE:DateIf you drive your personal automobile while on school business and you are involved in anaccident, by law, your own insurance policy is used first. The District liability policywould be used only after your liability policy limits have been exceeded. The District doesnot cover, nor is it liable, for comprehensive and collision coverage to your vehicle.PLEASE COMPLETE THE FOLLOWING INFORMATION . . . . .School:Date of Activity:Activity:Location:Address:Telephone #:

Field Trip Forms and Procedures Student Activity Field Trip Request Form Front of form completed (Purpose of Trip and Relevance must have a specific description; Destination – Please specify city and state) Account numbers noted (The Board would like to know wha