Form MCSFT-1

FIELDTRIPREQUESTFORM

Date of request: NameofEvent:


Updated 01/13/17*MCSFT-1*Page 1 of 2

Form MCSFT-1

School:Choose an item. Sponsor (Teacher/Coach): ContactNumber:

A.TripType:Choose an item.

OvernightTrip: ☐Yes ☐NoCompetition: ☐Yes ☐No

Complete forAthleticTrips:Sport:Level:☐9th ☐JV ☐Varsity *☐ See Attached Schedule

Complete forInstructional:Subject: Grade(s):

Complete for CTAE: Area: Grade(s):

Complete for Other:Grade(s):

HastheEvent,Play,orPerformancebeenapprovedasappropriateforstudents? ☐Yes ☐No ☐N/A

Funding Type:(Checkone)☐District ☐LocalSchool ☐OutsideVendor ☐Other:

Funding Detail:

B.Supervision: Adult/StudentSupervisingRatio: Elementary1:15 – Middle1:20 –High1:25(SupervisorsmustbeapprovedbythePrincipal) *List All Persons Attending:

C. Participation/Cost:

NumberofParticipants:RegularEducation: SpecialEducation: Adults:

CostPerStudent (student fees/donations): Miles round trip:X $1.50 per mile =

Driver Cost: ☐ Driver not needed (name of driver:) ☐ Transportation to assign driver at $10.00 per hour (4 hour

minimum) = Approximate cost of trip: Who is responsible for the bill?

D.Site/Date/Time:

DepartureSite:Date:Time:

Destination Site:Date:Time:

Destination Address:

Return Site:Date:Time:

E. TypeofTransportation:(markchoiceandcomplete)

☐System: #ofRegEdBuses:#ofSpEdBuses:(w/Lift)(w/o Lift) Car Seats:

Chest Harness:

☐PrivateCarrier:#ofBuses Nameof Carrier:

☐Other Explain:

F. CurriculumConnections:

See page 2 (Must be filled out completely)

G.Comments/Special Requests:

Note: A $25.00 charge will apply if bus(es) are returned unclean. (Ex. drink spills, trash on floor, etc.)

Name of person in charge:Date:

H. I have notified the Cafeteria Manager:☐Yes ☐N/A Date:

PLEASENOTE:

1.In all situationsthepermissionformssuppliedbytheMurrayCountySchoolDistrictaretobeusedtogainpermissionfromparents/guardians.

2.Thesupervisingteachermusthaveacopyofeachstudent’semergencycardoranotarizedmedicalhistoryforminhis/herpossessionduringall fieldtrips.

3.Forthedurationofthe fieldtrip,employeesandadultsupervisorsaredirectlyaccountablefortheiractionsasiftheywereresponsiblefor studentsonschoolpremises.Employeesandadultsupervisorsmustrefrainfrompersonalpractices,bothinandoutofthepresenceofstudents,

whichwouldbeinconsistentwiththeirresponsibilitiestosupervisestudents.

4.ThisformmustbekeptonfileatthelocalschoolandmustbesignedbythePrincipal.

Principal Name: ☐ Approved ☐ DeniedDate:

Updated 01/13/17*MCSFT-1*Page 1 of 2

Form MCSFT-1

Curriculum Connections:

  1. Howdoesthistriprelateto thecurriculum (Must include Standards, Big Ideas, Pre-Work, Field Trip Activities, Post-Work)?
  1. Whatarethearrangementsforstudentsnotattending?

Updated 01/13/17*MCSFT-1*Page 1 of 2