October 1, 2015
EHHS Faculty & Staff:
The Board of Education and East Hartford High School administration encourage and sanction student field trips, which are of value in helping to achieve each participating student’s educational objectives. In an effort to ensure a safe and consistent process, the school team has developed the following procedures in regard to scheduling field trips at EHHS.
Step One:
All Overnight Field Trips must be approved by the East Hartford Board of Education.
Check the Calendar of Field Trips in Mr. LeRoy’s house office and note the proposed trip on that day. There will be no more than 2 field trips allowed for any day.
Print, complete, and submit the EAST HARTFORD PUBLIC SCHOOLS Field Trip Request Form to Mr. LeRoy’s house office. Please refer to the timeline below regarding overnight trips:
o Out of the country trips must be submitted a minimum of 4 months prior to travel
o Out of the state trips must be submitted a minimum of 2 months prior to travel
o In-state trips must be submitted a minimum of 6 weeks prior to travel
Print, complete, and submit the EAST HARTFORD PUBLIC SCHOOLS Field Trip Request Form to Mr. LeRoy’s house office four weeks prior to the overnight trip requirements listed above.
Make sure you have your Department Supervisor Sign on the Field Trip Supervisor signature line along with the teacher in charge of the trip.
The field trip approval form must be approved by Central Office and will be returned within 7 calendar days of the trip.
Once the Field Trip is approved by Central Office, follow the next steps below
(Trip approval forms will be returned to the teacher within one week of the trip).
Distribute and collect a “Field Trip Permission Slip/Consent and Waiver” form and “Medical Form” for all trip attendees.
Submit all medical permission slips to the nurse’s office, giving their office three (3) FULL DAYS of medical review before your trip leaves. For example, if you turn in your slips after the start of school on a Tuesday, the earliest your trip can leave is that Saturday, giving the nurses Wed, Thurs and Fri for review—3 FULL DAYS. If those slips are not turned in time, the field trip will not take place or late addition students will not be allowed to go.
If administering medication, a staff member must be trained by the school nurse (within one year) to administer medications on a Field Trip. Medications must be carried by the medication-trained staff member at all times during the Field Trip. Controlled Medications must be kept in a locked container and with the medication-trained staff member at all times.
All transportation information and trip tickets must be completed and turned in to Madeline Harris in the SAA office.
Your field trip roster must be submitted to Mr. LeRoy’s office 24 hours in advance so that we can code the student attendance appropriately to avoid incorrect automated absence phone calls to parents.
On the day of the trip, leave your cell phone number in the main office, in the event of an emergency. Your final field trip list of attendees should then be e-mailed to all House Offices, Angela and Sue in the main office, specifically noting any students that are absent.
School uniforms are required for all field trips unless prior administrative approval is given.
All required documents must be completed with enough time for you to submit the medical permission slips to the nurse’s office at least 2 full weeks BEFORE your actual field trip leaves. If those slips are not turned in time, the field trip will not take place.
Following any field trip the final field trip report must be submitted to my office. This document provides a brief description of the trip and whether or not the learning objective was met.
All necessary day trip forms are attached in the appendices. For questions regarding the Field Trip process, contact Mr. LeRoy’s office. Any medical inquiries may be directed to the nurse by the requesting trip supervisor.
Thank you for your continued commitment to excellence and student learning at EHHS!
Joseph LeRoy
Assistant Principal
East Hartford High School
For office use only:
Central Office Approval: Date: ______House Office Received: Date: ______
Pre-Trip Requirements: Permission Slips Medical Forms Transportation Trip Roster (24 hours)
If necessary Requirements: Expense Report Finances Volunteer(s) Cafeteria Incident Report
Post-Trip Requirements: Final Trip Report
EAST HARTFORD PUBLIC SCHOOLS
Field Trip Request Form
** Note: This form must be submitted to the Assistant Superintendent’s Office for approval
at least two (2) weeks in advance.
GENERAL INFORMATION
School: Willowbrook Field Trip Application Date:
Goodwin Date(s) of Trip:
Hockanum Destination:
Langford Group(s) & Grades Participating:
Mayberry
Norris
O’Brien Number of Students:
O’Connell Time of Departure:
Pitkin Time of Return:
Silver Lane
Sunset Ridge EHPS Staff Contact Name:
East Hartford Middle School EHPS Staff Contact Number:
East Hartford High School
CIBA Field Trip Contact Name:
Synergy Destination Contact Number:
Woodland
TRIP INFORMATION
What is the itinerary for this trip (* please attach itinerary), and what are the specific connections to the curriculum?
What are the central learning objectives for this trip? In other words, how will it enhance student learning?
What is the plan for transportation for this field trip?
What adults (administrators and/or teachers) will be chaperoning this field trip?
What is the cost per student for this field trip?
What arrangements, if any, have been made for lunch?
What arrangements, if any, have been made for those who cannot afford the cost of the field trip?
Are there any students who are participating in the field trip that have medical needs (e.g. EpiPen, insulin)? ______(Yes/No)
If so, what plans have been made with the school nurse to meet the needs of these students?
Are there any Special Education students who are participating in the field trip that require special transportation? ______(Yes/No)
If so, this request must also be approved by the Director of Pupil Personnel Services (See signature line below)
Are substitutes are required to cover the adults who are participating in the field trip? ______(Yes/No)
If so, how many? ** Please be sure to complete and submit the necessary substitute request form.
Are there any volunteer/chaperones, other than BOE employees that will accompany students? ______(Yes/No)
If so, please attach a signed copy of the volunteer/chaperone agreement.
Does a vendor/outside contractor, require a signed contract or a certificate of liability insurance? ______(Yes/No)
If so, has the contract been reviewed and approved by risk management? ______(Yes/No)
REQUIRED SIGNATURES
Field Trip Supervisor: Date: ______
School Nurse: Date: ______
Principal: Date: ______
REQUIRED APPROVAL SIGNATURE
Dir. Pupil Personnel Services: Date: ______
(only required if special education transportation is needed)
APPROVED NOT APPROVED
Assistant Superintendent: Date: ______
APPROVED NOT APPROVED
Additional Information Requested:
EAST HARTFORD PUBLIC SCHOOLS
PROPOSAL FOR OVERNIGHT TRAVEL
East Hartford Board of Education Policy 6153/Regulation 6153a-e
Group Name: / Anticipated # of students:
Dates of Trip: / Number of missing school days:
Date:
Destination / Time Returning:
Educational Purpose:
Gender and names of chaperones. Give ages of chaperones under 25 and list relationship to system or staff (spouse, child, staff member, parent, etc.) .
1 / 4 / 7
2 / 5 / 8
3 / 6 / 9
Principal Signature / Date:
Total Cost per student:
Breakdown of cost (including fundraising efforts if applicable):
Name of Travel Agency/Group and Contact Person:
Transportation Type
(Bus, Car, Plane, etc.)
Fundraising- Describe any efforts and how funds will be distributed:
Name of Supervising Teacher:
Signature of Supervising Teacher: / Date:
Signature of Department Supervisor: / Date:
Signature of Principal: / Date:
Signature of Superintendent: / Date:
Signature of Board of Education: / Date:
*Final report to Assistant Superintendent’s office is due on or before the First BOE Meeting following the trip.
EAST HARTFORD PUBLIC SCHOOLS
PROPOSAL FOR OVERNIGHT TRAVEL – ATHLETICS
Name of School: / Date of Request:Sport: / Anticipated # of students:
Dates of Trip: / Number of missing school days:
Date:
Destination / Time Returning:
Gender and names of chaperones. Give ages of chaperones under 25 and list relationship to system or staff (spouse, child, staff member, parent, etc.)
1 / 2 / 3
4 / 5 / 6
7 / 8 / 9
Principal Signature / Date:
Total cost per student for trip:
Transportation Type
(Bus, Car, Plane, etc.)
Lodging Site:
Address:
Telephone Number:
Name of Supervising Coach:
Signature of Supervising Coach: / Date:
Signature of Athletic Directors: / Date:
Signature of Principal: / Date:
Signature of Superintendent: / Date:
Signature of Board of Education: / Date:
*Final report to Assistant Superintendent’s office is due on or before the First BOE Meeting following the trip
EAST HARTFORD PUBLIC SCHOOLS
STUDENT OVERNIGHT TRAVEL MEDICAL FORM
Pupil Name / Age / GenderLast / First / Middle
Address
Number and Street / Town / Zip
Date of Birth / Home Phone / Work Phone
Parent/Guardian Name
Parent/Guardian Daytime Phone
Emergency Contact (If unable to contact Parent/Guardian) / Phone Number
Who is responsible for medical payments? / Individual / Insurance
If individual, please provide credit card information: / Visa / MasterCard / Other (name card)
Name on credit card / Exp. Date: / Signature
Medical Insurer / State
Policy # / Name on Card
Physician’s Name / Phone Number
Copy of Insurance Card provided.
BRIEF MEDICAL HISTORY
List any special Health Conditions (including any medications and/or dosage if taken)1
2
3
Additional Information
Restrictions from any activities: /
No / Yes (explain):
Medications Needed: /
No / Yes (explain):
*If taken regularly, please bring labeled container supply to the school nurse.
Has your child received a tetanus shot within 6 years? / No / Yes
I, parent or legal guardian of ______(my child) authorize East Hartford Public schools to obtain medical care for my child in the event of such care is necessary. I understand that, if possible, I will be contacted in the event my child needs medical attention. I grant to a licensed health provider and accredited hospital permission to perform any medical and/or surgical procedures that are essential for the treatment of my child and agree to be responsible for payment of such care. I release the East Hartford School System, it’s employees, and agents from any damages, liability, or loss resulting form their securing in good faith medical care for my child.
Signature: / Date:
EAST HARTFORD PUBLIC SCHOOLS
K-12 STUDENT FIELD TRIP
PERMISSION SLIP/CONSENT AND WAIVER
(Regulation 6153 a, b)
Name of PupilField Trip:
Date of Field Trip:
CONSENT AND WAIVER
I recognize that there are real and inherent dangers in traveling significant distances by air, bus, or train. I fully understand and accept that my child, the above named student, may be subject to these dangers while traveling to and from the destination of the field trip described above, and while participating in the trip at that destination, and that his or her death or serious bodily injury may result. Despite these dangers, I hereby request that the above named student be allowed to participate in the trip planned and all trip-related activities. I specifically consent to his/her participation, and waive any and all claims against the East Hartford Board of Education, its officers, directors, employees, agents and contractors for any injury, including, but not limited to death and serious bodily injury, that may result from any inherent risk in my child’s participation in this field trip. The inherent risks involved in participation in this field trip include those injuries that result from the circumstances or actions of persons who are not employees or agents of the East Hartford Public Schools.
In addition, if the above named student requires any emergency medical procedures or treatments during the trip, I consent to the trip supervisor(s) taking, arranging for, or consenting to the procedures or treatments in his/her discretion. I hereby release the East Hartford Board of Education, and their officers, directors, employees, personnel and contractors, from and against any and all claims and liability arising from or related to the provision, authorization and administration of medical treatment, services and medication to my child in accordance with these provisions.
In addition, approval is also subject to the following conditions:
a. The Board reserves the right to reconsider the approval of this trip at any time between now and the time of departure of this trip.
b. In the event that the Board decides at any point to rescind its approval of this trip, thereby canceling the trip, the Board will not be responsible for any financial losses or penalties incurred by the affected students or their parents or guardians.
EAST HARTFORD PUBLIC SCHOOLS
K-12 STUDENT FIELD TRIP (Revised-October 1, 2015)
PERMISSION SLIP/MEDICAL FORM
Name of PupilActivity:
Place:
Date:
Time Leaving School: / Time Returning:
Supervising Teacher(s)
Cost: / Permission and Money Due:
Please note: If trip exceeds the length of a regular scheduled school day, students must be picked up within 30 minutes upon return to school or the police may be contacted.
Medical Information: All 3 questions below MUST be completed in order for your child to attend the trip.
------
1. Will your student be taking medication on this trip? Yes No
If yes, please describe the medication: ______
Remember a Doctor’s order is needed for all types of medications, even for over-the-counter medications (This needs to be obtained by the parent from the Doctor.)