4531-E.1-2

PHOENIX CENTRAL SCHOOL DISTRICT
Student Travel Proposal Form

(for overnight travel or mileage beyond 75 miles)

Name of Group/Organization: _____________________________________________________________________

Advisor(s) in Charge: ___________________________________________________________________________

Destination:  __________________________________________________      Date(s): _______________________

Reason for Trip (rationale, educational benefit, etc): ___________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

 

 

Complete Itinerary of Trip: _______________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

 

 Number of Students Participating: ____________                 Number of Chaperones: __________________________
(1 chaperone for every 10 students; staff members need to be a minimum of 1/3 of chaperones)

Names of Chaperones: __________________________________________________________________________

_____________________________________________________________________________________________

 

Transportation Arrangements: ____________________________________________________________________

 

Cost Information and Sources of Funding:

(Including provisions for students, if any, who are unable to pay and how their costs will be covered)

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Advisor's Signature: ________________________________________        Date: ___________________________

Administrator's Signature: ___________________________________         Date: ___________________________

Superintendent's Signature: __________________________________         Date: ___________________________

 

 

FIELD TRIPS AND EXCURSIONS - EXHIBIT
PHOENIX CENTRAL SCHOOL DISTRICT

 

 

4531.E1

Dear Parent/Guardian:

Your child’s teacher, ________________________, is now in the process of planning a field trip to ___________________________ on _______________. It is school procedure that any student who may have an allergic reaction to any allergen (bee stings, foods, and/or environment stimuli) and receives medication must be accompanied on the trip by someone who is capable of administering the medication.

Your child will not be allowed to attend the trip without an adult to assume this responsibility. If you have any questions, please call the health office.

Thank you,

School Nurse

---------------------------------------------------------------------------------------------------

 

 

 

Please Tear and Return

I hereby give my permission for ________________________________ to

Child’s Name

participate in the school field trip planned to ______________________________

on __________________. I will/will not be able to accompany my child on this trip. It is understood that if an adult capable of administering medication is not available, my child will remain in school and not take part in this field trip.

 

___________________________________

Parent/Guardian Signature

 

4531-E.2

FIELD TRIPS AND EXCURSIONS – EXHIBIT

PHOENIX CENTRAL SCHOOL DISTRICT
Phoenix, New York 13135

Date  __________________

Dear __________________

Re:____________________

It is Phoenix Central School procedure to exclude children who require medication following an allergic reaction from a field trip unless accompanied by an adult to administer the medication.

These children will be allowed to attend field trips if they have been instructed in the administration of their own medication by their physician and the attached form is signed and returned to school.

School Nurse ___________________

Phone Number __________________

----------------------------------------------------------------------------------------------------

 

 

I have instructed ___________________________________ in the administration of medication either using an Epi-pen or a bee sting kit. He/She should be able to administer it on a school field trip.

 

Signature of Physician _____________________________

 

Signature of Parent/Guardian ________________________

 

Adoption date: January 1, 1993
Reviewed on:  November 7, 2006

Adoption date: December 11, 2006