FLORENCE UNIFIED SCHOOL DISTRICT #1
ACTIVITY TRIP REQUEST FORM
Date Submitted:08/27/2013
Section 1: Your Contact Information
Submitted by: John Allee
Your School Site: Florence K-8
Your position : Principal
School Phone Number : 520-866-3540 Extension: 2005
Your Emergency Contact Number: 520-280-3256
Are you designated the trip leader? YES NO
If no, who is the designated trip leader? Jill Gammill
Phone Number for designated trip leader: 480-239-5946
Section 2: Activity Dates/Location/Specific Travel Information
Type of Activity: Out of State Travel In-State Travel (More than 75 miles)
Date(s) of trip: 05/29/2014 through 06/02/2014
Destination of trip: Washington D.C.
Date of departure: 05/29/2014 Time of departure: 10:00PM
Date of return: 06/02/2014 Time of return: 6:00PM
Purpose of trip: The purpose of the trip is to experience the history of our nation.
Briefly describe trip activities: The students will visit historical sites like Matha's Vineyard, The Lincoln Memorial, and the Smithsonian Museum to name a few.
Name/Address of Site: Name: School Tours of America, LLC
Address: PO Box 550379
City/State Houston , Texas Zip Code: 77255
Contact Person at Site (Non-School Personnel): School Tours of America, LLC Emergency Number
Phone Number of Contact Person: 1-866-491-1543
Means of transportation selected: Private Charter District Provided Buses Parent Provided
In general, describe the route to the destination: The students and chaperone will fly from Phoenix, AZ to Wahsington, DC, and then will travel via motorcoach throughout the city.
Number of Students Participating: 8
Number of Chaperones: 1
Estimated total cost of activity trip: $13,041
Estimated cost per student participant: $1,449
Section 3: Parent Permission Slips/Emergency Medical Release Forms
Permission slips/medical release forms have been collected from all students?
YES NO
If NO, who is responsible to collect these documents prior to departure?
Jill Gammill will collect the permission slips prior to departure.
Trip leader has copies of parent permission/medical release forms that will be accessible during the trip? YES NO
If NO, who is responsible for making these copies?
Jill Gammill will collect the permission slips prior to departure.
Copies of the parent permission/medical release forms have been left at the school site office? YES NO
If NO, who is responsible for making copies for the office?
Jill Gammill will collect the permission slips prior to departure.
Principal has reviewed all documents and approved the Activity Trip recommends sending Agenda Item to the Governing Board? YES NO
Name of Principal: John Allee
Will Requestor be present at Governing Board Meeting to respond to questions? YES NO
Please provide any other pertinent information:
Section 4: Chaperones/Contact Phone Numbers
List of Chaperones and Phone Numbers:
1. Jill Gammill Position: 7th/8th Grade Social Studies Teacher Phone Number: 480-239-5946
2. Position: Phone Number: --
3. Position: Phone Number: --
4. Position: Phone Number: --
5. Position: Phone Number: --
6. Position: Phone Number: --
7. Position: Phone Number: --
8. Position: Phone Number: --
Section 5: Activity Trip Exposure Analysis Checklist
Is the location of the activity indoors or outdoors? Indoors Outdoors Both
Are special clothing needs such as shoes, jackets, or gloves required? Yes No
Does the trip location include exposure to insect or animal bits, falling rocks, puncture wounds from plants, or eye irritation from dust or other airborne particles? Yes No
Does the trip require climbing above or below the ground floor? Yes No
If yes, are walkways well marked? Yes No N/A
Do they include hand or guardrails? Yes No N/A
Are they maintained in good condition? Yes No N/A
Have extraordinary exposures been included on the Activity Trip Permission Form to provide an informed consent from parent or guardian? Yes No N/A
Are first aid services available at the trip location in the event of an injury or illness?
Yes No
Are food and water available at the trip location? Yes No
If not, will the students bring their own food and water? Yes No N/A
Are facilities available to safely store food and water? Yes No N/A
Has the travel route been planned in advance? Yes No
Will transportation make stops traveling to or from the trip location? Yes No
If yes, have stops been planned to maintain student control and safety? Yes No N/A
Is adequate parking available for safe vehicle loading, unloading, parking, and turn around? Yes No
Does the learning experience involve direct contact with plants or animals? Yes No
If yes, have students been questioned about potential allergic reaction? Yes No N/A
Is prior evidence of liability insurance protection required by the trip location owner to allow use of the facility or property? Yes No N/A
If trip includes residence at a camp facility, does the owner require proof of student accident insurance? Yes No N/A
If the trip includes a wilderness program, have special arrangements been made for emergency or medical evacuation? Yes No N/A