4118 W. Rosecrans Avenue, Lawndale, California 90260
Home of the Olympians
FIELD TRIP PACKET 2016-2017
Field trips can be a positive supplement to the academic program. Below are the procedures required for each field trip to ensure the safety of students and staff members.
ALL field trips must be approved and calendared by school administration. This includes trips that take place after school hours and/or on non-school days.
Procedures:
1. Read and complete the Field Trip Packet. This packet includes:
· Field Trip Expectations & Responsibilities for Teachers & Students
· Field Trip Request Form
· Educational Value Statement
· Field Trip Attendance Roster
· Parent Permission & Emergency Information Form
· CVUHSD Wavier Agreement Form
· Medical Release Form
· Trips Requiring Board Approval Information
· Board Agenda Analysis Forms
Submit the completed Field Trip Information Package with purchase requisition form for bus transportation (if applicable) and Board Agenda Analysis (if applicable) to Dr. Ho Rm. 112, ext. 2303.
*Dr. Brown Has Final Approval On All Field Trips*
NO FIELD TRIPS ALLOWED DURING CAHSEE/STAR/SBAC TESTING!
2. One week prior to the field trip submit a list of students to Dr. Ho, Rm. 112, ext. 2303 and verify that these students are not on the *NO GO LIST*.
3. Notification of final approval of the field trip will be placed in your box immediately following approval.
4. Every student participant must have a parent permission card, off-campus permit card, and medical release form signed a week prior to the field trip date.
5. Submit a list of students who participated in the field trip no later than 8:00 am on the school day immediately following the trip (including weekend field trips) to the Attendance Office.
6. Place a copy of the list of students who attended the field trip in teachers’ mailboxes the day following the field trip.
LEUZINGER HIGH SCHOOL
FIELD TRIP EXPECTATIONS AND RESPONSIBILITIES
Student Rules and Expectations
1. Adhere to the Olympian Code of Conduct even when away from the school site.
2. Submit Parent Permission for Excursion card and Medical Release Form signed by parent/guardian to the field trip sponsor.
3. Submit Off-Campus Permit card signed by teachers of classes that will not be attended as a result of field trip participation to the field trip sponsor.
4. Complete in a timely manner all assignments missed as a result of attending the field trip.
Teacher Responsibilities and Expectations
1. If you are planning to transport students in your car or a district vehicle at any time during the 2016-2017 school year, you will need to be approved as an authorized driver by your Principal and by Dwayne Eatmon III, Director of Security on x4457 by completing the *Authorization to Transport Students* Form. Forms are available in the Main Office.
2. Call Sub-Finder and contact the principal’s secretary for substitute coverage if needed.
3. Provide detailed lesson plans and seating charts for your classes that will need substitute coverage.
4. Verify that students attending field trip are not on the no-go list.
5. Distribute forms to students immediately after receiving approval signatures.
6. Contact Jennifer Le at the district office to confirm that a bus has been secured.
7. Submit confirmed field trip attendance list to Liz Contreras 2 days before the trip.
8. Verify that all students have signed permission forms and emergency information prior to leaving campus.
9. Keep student emergency information and medical release forms accessible during the entire field trip.
10. Take accurate attendance during the field trip.
11. Use the Field Trip Attendance List to submit names and ID numbers for all students who attended the field trip. Submit copies to the Attendance Office no later than 8:00am on the school day immediately following the field trip.
12. Place a copy of the list of students who attended the field trip in teachers’ mailboxes the day following the field trip.
LEUZINGER HIGH SCHOOL
FIELD TRIP REQUEST FOR APPROVAL
Requests must be submitted to Dr. Ho a minimum of 1 month prior to the trip.
Field trips that travel overnight, out of LA County, out of CA State, or include water sports/boat travel require 2 MONTHS advance notice and CVUHSD Board Approval.
Organization/Class: ______
Field Trip Destination: ______
Address: ______City: ______Zip: ______
Name and Title of Contact at the Field Trip Destination: ______
Destination Contact Phone Number: ______
Date of Departure: ______Date of Return: ¨ same day ¨ other ______
Departure Time: ______Return Time: ______
Sponsor’s Name ______Cell # ( )
Meet-up Location (be specific): ______Field Trip Meet-up Time:______
Sponsors are required at a ratio of one sponsor per 12 students. If additional sponsors are needed, please indicate names and positions (teacher, instructional aide, parent, etc.).
Name: ______Position: ______
Name: ______Position: ______
Name: ______Position: ______
EXPENSES:
· Transportation (check one): ¨ 52-seat bus ¨ 48-seat bus ¨12-seat van
¨ *other ______
o * If planning to transport students in private vehicles or van, each driver must have an approved CVUHSD Authorization to Transport Students on file or submit one with all required documentation at least four weeks in advance for approval. The form is included in this packet.
o Funding source for transportation: ______
· Ticket or admission charges: ______Funding source: ______
· Other expenses (please explain and include funding source): ______
I have read and fully understand the field trip policies and procedures. I acknowledge that this field trip cannot be approved without an Educational Value Statement and that I must submit the Field Trip Attendance List no later than 8:00am on the school day immediately following the field trip.
Sponsor’s Signature: ______Date: ______
Approvals: ______Howard Ho (AP) Pamela Brown (Principal)
LEUZINGER HIGH SCHOOL
FIELD TRIP EDUCATIONAL VALUE STATEMENT
Please provide short statements as evidence that this trip has educational value, supports course learning standards and justifies students missing other classes.
· What is the academic purpose of this field trip?
· What learning standard(s) or ESLR(s) is/are addressed by this field trip?
· How will you connect this field trip to content and skills students need to master in your class?
· What activities will students be expected to complete prior to, during, and/or after the trip?
· How will this field trip help students in making college/career decisions?
YOUR TRIP WILL NOT BE APPROVED WITHOUT THIS VALUE STATEMENT!
LEUZINGER HIGH SCHOOL
Field Trip Confirmed Attendance List
This form must be submitted to Liz Contreras in the main office at least 48 hours before the trip.
Date of Trip:______Program/Academy: ______
Destination:______Number of Subs requested: ______
Name (Last, First) / ID# / Name (Last, First) / ID#1. / 26.
2. / 27.
3. / 28.
4. / 29.
5. / 30.
6. / 31.
7. / 32.
8. / 33.
9. / 34.
10. / 35.
11. / 36.
12. / 37.
13. / 38.
14. / 39.
15. / 40.
16. / 41.
17. / 42.
18. / 43.
19. / 44.
20. / 45.
21. / 46.
22. / 47.
23. / 48.
24. / 49.
25. / 50.
Sponsor’s Name: ______
Sponsor’s Signature: ______Date: ______
LEUZINGER HIGH SCHOOL
FIELD TRIP ATTENDANCE LIST
This form is due to the Attendance no later than 8:00am on the school day
immediately following the field trip.
These students submitted all required forms and attended a school-approved field trip on:
______/_____/______
Day of the week Month Date Year Time/Period
Destination:______Sponsor______
Name (Last, First) / ID# / Name (Last, First) / ID#1. / 26.
2. / 27.
3. / 28.
4. / 29.
5. / 30.
6. / 31.
7. / 32.
8. / 33.
9. / 34.
10. / 35.
1. / 36.
12. / 37.
13. / 38.
14. / 39.
15. / 40.
16. / 41.
17. / 42.
18. / 43.
19. / 44.
20. / 45.
21. / 46.
22. / 47.
23. / 48.
24. / 49.
25. / 50.
______
Sponsor Signature Date
LEUZINGER HIGH SCHOOL
SACK LUNCHES FOR FIELD TRIP
Please fill out this form ONLY if you need the school to provide sack lunches for your students.
This form is due to Liliana Garcia () in Food Services at least 5 days prior to the trip.
______/_____/______
Day of the week Month Date Year Time/Period
Destination:______Sponsor______
Name (Last, First) / ID# / Name (Last, First) / ID#1. / 26.
2. / 27.
3. / 28.
4. / 29.
5. / 30.
6. / 31.
7. / 32.
8. / 33.
9. / 34.
10. / 35.
1. / 36.
12. / 37.
13. / 38.
14. / 39.
15. / 40.
16. / 41.
17. / 42.
18. / 43.
19. / 44.
20. / 45.
21. / 46.
22. / 47.
23. / 48.
24. / 49.
25. / 50.
______
Sponsor Signature Date
FIELD TRIP PERMISSION & EMERGENCY FORM
All students attending an approved field trip must submit the following forms to the trip sponsor.
1. Field Trip Permission & Emergency Form (this form)
2. Medical Release Form
These forms must be accessible to the sponsor during the entire field trip.
Centinela Valley Union High School District
WAIVER, RELEASE AND INDEMNITY AGREEMENT
ASSUMPTION OF RISK FOR PARTICIPATION
IN VOLUNTARY ACTIVITY
Student’s Name: ______School: LEUZINGER HIGH SCHOOL
Description of Activity: ______
Date(s) of Activity: ______
By my signature below, I hereby give permission for my son/daughter to participate in the above described activity. I realize that this activity is voluntary and is not a mandated requirement of the Centinela Valley Union High School District curricular or extra-curricular program. The undersigned is specifically aware and confirms by executing this document that they are aware that participation in such an activity presents a risk of personal injury, bodily injury, property damage or wrongful death, and that the undersigned’s child may injure himself or herself, or be injured by other participants related to the activity. The undersigned is specifically aware and acknowledges being aware of the risk that he or she may be hurt or injured by participating in any aspect of this activity.
For and in consideration of permitting the above named child to participate in the activity described above, the undersigned hereby voluntarily releases, discharges, waives and relinquishes any and all actions or causes of action for personal injury, bodily injury, property damage or wrongful death occurring to him/herself arising in any way whatsoever as a result of engaging in said activity or any activities incidental thereto wherever or however the same may occur and for whatever period said activities may continue. The undersigned does for him/herself, his/her heirs, executors, administrators and assigns hereby release, waive discharge and relinquish any action or causes of action, aforesaid, which may hereafter arise for him/herself and for his/her estate, and agrees that under no circumstances will he/she or his/her heirs, executors, administrators and assigns prosecute, present any claim for personal injury, bodily injury, property damage or wrongful death against the District, its Board, or any of its officers, agents, servants, or employees for any of said causes of action. The foregoing waiver does not apply in the event of the sole negligence or willful misconduct of the District.
The undersigned hereby acknowledges that he/she knowingly and voluntarily assumes all risks of bodily injury to his/her child, as states, and expressly acknowledges their intention, by executing this instrument, to exempt and relieve the District, its Board, officers, agents, and employees, from any liability for personal injury, bodily injury, property damage or wrongful death that may arise out of or in any way be connected with the above-described activity. I have read the foregoing and have voluntarily signed this agreement. I am aware of the potential risks involved in this activity and I am fully aware of the legal consequences of signing this instrument.
______
Parent/Guardian Signature Date Student’s Signature Date
______
Parent/Guardian Name (Please Print) Student’s Name (Please Print)
______
Street Address City State Zip
______
Home Telephone Number Work Telephone Number
Centinela Valley Union high SCHOOL district
STUDENT PARTICIPATION IN DISTRICT-SPONSORED VOLUNTARY FIELD TRIP
PARENTAL PERMISSION, ASSUMPTION OF RISK, AND
MEDICAL TREATMENT AUTHORIZATION
Date ______
Student's Name: ______has permission to participate in the following field trip:
Destination/Nature of Activity______
(Please be specific, e.g., Concert at UCLA.)
Special Instructions:______
(e.g., Bring sack lunch.)
Departure Return
Date: ______Time: ______Date: ______Time: ______
Person in Charge: ______Position: ______School: ______
Type of Transportation: District Bus/Vehicle Walking Other:______
Health or special needs: Check as appropriate.
My student has no special health needs the staff should be aware of, and no medication is required on the trip.My student has a special need, and instructions are attached. Number of attached pages:______.
Other:
In the event of illness or injury, I do hereby consent to whatever x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care and emergency transportation considered necessary in the best judgment of the attending physician, surgeon, or dentist and performed under the supervision of a member of the medical staff of the hospital or facility furnishing medical or dental services.
I fully understand that participants are to abide by all rules and regulations governing conduct during the trip.
As provided for in California Education Code Section 35330, I agree to waive all claims against the Centinela Valley Union High School District (District) and hold the District, its officers, agents and employees, harmless from any and all liability or claims, which may arise out of or in connection with my child's participation in this activity. This waiver shall not apply to any occurrences which may arise solely out of the negligence of the District, its employees or agents.
______Work Phone ( )______
Signature (Parent/Guardian) (Please Print Name)
Home Phone ( ) ______
______Student’s Date of Birth Student’s Signature
Family Medical
InsuranceCarrier (REQUIRED):______Policy Number (REQUIRED):______
(e.g., Blue Cross)
In the event of an emergency, please contact: