School/Program: Trip Destination(s): Trip Departure Date/Time: Trip Return Date/Time: Number of School Days: Field Trip Coordinator: Contact Number: Educational Benefit of the Field Trip: Describe Transportation Arrangements: Transportation Estimated Round Trip Distance: A District-provided school bus is always preferred Directions to Site: If a long trip or to a remote location, please attach route map Field Trip Activities Activities planned during the trip (please be specific): The Student Activities Matrix can help you identify which activities may be considered high risk, and need to be reviewed by Safety Services/Risk Management. If you re not sure, please ask: 354-4635. **Attach information including brochures, links to trip locations, etc. 3/7/2016 jkv2016.1.3 Page 1 of 7
Potential Site Hazards (exposure to animals, water, heat, cold, insects, snakes, traffic, uneven surfaces, heights, etc.) Physical Activity Risks (dehydration, strains, sprains, overexertion, etc.): Plan for informing parents/guardians of potential activity risks: Permission Slip Inherent Risk Release Email Meeting Number of students: Supervision Grade level of students: Supervision (Chaperones) # of Staff # of SPS Registered Volunteers that are 21 years of age Are any special qualifications required or is training needed for supervisors for this trip? If yes, please describe: All chaperones must be 21! Recommended minimum supervision ratios: elementary school age: 1 to 10, middle/high school age: 1 to 20. Food & Lodging How will food and snacks be provided? For overnight trips, how will lodging be provided? Make sure to describe how you will separate lodging by gender and by staff/student, and how you will provide supervision overnight. 3/7/2016 jkv2016.1.3 Page 2 of 7
Do any students need special accommodations? Yes No If Yes; describe accommodations: Trip Financing What are the estimated expenses(s) of the What are the plans to finance these expenses? trip? Attach a trip budget if you have one. Will fundraising be needed? If yes, please attach a fundraising plan. Student Attire & Equipment Required student clothing/footwear/equipment: Closed-toed shoes or boots Long pants Recommended student clothing/footwear/equipment: Rain jacket For the above, consider weather, terrain,etc. Location Facilities Available at Location: Potable water Bathrooms Parking Site Specific Considerations and Precautions (communication issues, remoteness and EMS response, environmental hazards, etc.): 3/7/2016 jkv2016.1.3 Page 3 of 7
Expected weather for this trip location and date(s) based on National Weather Service (NWS) Forecast/Historical Data: Name of Field trip supervisor responsible for checking day of trip and/or day of activity NWS weather report(s): Emergency Planning Contingency Plans (in the event of inclement weather, student illness or injury, etc.): Student Illness or Injury: Inclement Weather: For the above, consider communication, potential weather impacts, Fire/EMS response time to location, etc. Safety/Emergency Equipment or Personnel Needs (first-aid kits, lifeguards, traffic control, etc.): A first aid kit (or kits) appropriate to the size and nature of the field trip is always required. Site Map(s) and Other References Attached: Yes No 3/7/2016 jkv2016.1.3 Page 4 of 7
Travel Itinerary Date Time Destination Trip Management Position Name Contact Number(s) Trip Coordinator Trip Supervisors Email Current First Aid? 3/7/2016 jkv2016.1.3 Page 5 of 7
Trip Supervisors(cont.) Supplies & equipment for field trip supervisor(s) to bring: Fully charged cell phone First aid kit Sunscreen Bottled water Student medications 3/7/2016 jkv2016.1.3 Page 6 of 7
Date reviewed with Principal/Program Director: Review Items identified during plan review that need to be addressed before final approval (e.g., parent permission forms or releases completed, contract(s) reviewed by purchasing, driver training, volunteers registered, first aid training current, trip plan review by risk management, etc.): Consult with the student activities matrix and have all field trips that include high risk activities reviewed by risk management. Reviewed by Risk Management? Yes No Approved by Risk Management Yes Yes, with conditions No If approved by Risk Management, attach email with approval and any conditions that need to be met 3/7/2016 jkv2016.1.3 Page 7 of 7