Revised August, 2012
Form 260-1
NORTHERN LIGHTS SCHOOL DIVISION #113
FIELD EXPERIENCE REQUEST FORM
(Required for overnight, out-of-province, out-of-country, and on-the-water trips)
1. SCHOOL:
DATES OF TRIP:
COORDINATORS FOR TRIP:
NATURE OF TRIP:
PURPOSE OF TRIP:
SUPERVISION:
TEACHERS: POSITION ON STAFF/SUBJECTS TAUGHT:
OTHER RESOURCE PERSONNEL FUNCTION ON TRIP:
2. IF CANOE TRIP; GIVE NAME(S) OF SUPERVISORS AND CANOE INSTRUCTORS’ QUALIFICATIONS (CERTIFICATE NO. IF AVAILABLE):
3. DESTINATION:
4. ITINERARY (DATES, TIMES, PLACES AND ACTIVITIES, ATTACH IF NECESSARY):
5. DEPARTURE: DATE TIME
RETURN: DATE TIME
6. A) CLASS(ES) INVOLVED:
B) NUMBER OF STUDENTS: BOYS GIRLS TOTAL
C) AGE RANGE:
7. MODE OF TRANSPORTATION:
8. PROVISIONS:
A) MEALS:
B) ACCOMMODATIONS:
C) MEDICAL CARE IN THE EVENT OF AN ACCIDENT:
D) DAILY CONTACT ARRANGEMENTS MADE AT THE COMMUNITY LEVEL WITH FIELD GROUP:
9. FIELD EXPERIENCE BUDGET:
A) REVENUE SOURCES AND AMOUNTS (include fund-raising amounts):
TOTAL
PLAN FOR DISPERSAL OF RAISED FUNDS IF TRIP IS CANCELLED:
______
______
B) COSTS:
COST TO EACH STUDENT:
COST COVERED BY FUNDRAISING:
COST TO THE SCHOOL: (Decentralized budgets are
not to be used for out-of-country trips)
TOTAL:
10. NUMBER AND DURATION OF SUBSTITUTE TEACHERS REQUIRED, IF ANY?
11. HAS PARENTAL PERMISSION BEEN OBTAINED FOR ALL STUDENT PARTICIPANTS USING THE PARENTAL INFORMED CONSENT AGREEMENT FORM?
YES NO
12. WHAT PROVISIONS HAVE BEEN MADE FOR STUDENTS UNABLE TO PARTICIPATE IN THE TRIP?
13. HAVE ANY STUDENTS BEEN REFUSED PARTICIPATION ON THE TRIP? IF SO, LIST NAME(S) AND REASON(S):
______
14. WHAT SPECIFIC SUPPORT IS REQUIRED FROM THE BOARD?
ADVANCE REQUIRED: YES NO AMOUNT
CHEQUE PAYABLE TO:
MADE OUT BY: TO BE PICKED UP ON:
Date Date
15. FOR OUT-OF-PROVINCE AND OUT-OF-COUNTRY TRIPS HAVE MEDICAL INSURANCE, INSURANCE AGAINST LOSS OF LUGGAGE AND PERSONAL ARTICLES, AND PERSONAL ELECTRONIC EQUIPMENT BEEN PURCHASED BY THE PARENTS?
YES NO
16. WHAT ALTERNATE PLANS HAVE BEEN MADE FOR UNFORESEEN ALTERATIONS TO THE ORIGINAL PLAN?
17. NAME OF STUDENTS PARTICIPATING (ATTACH LIST GIVING NAME, GENDER AND AGE):
SCHOOL-BASED APPROVAL:
DATE SIGNATURE OF SUPERVISING TEACHER(S)
DATE SIGNATURE OF APPROVAL BY PRINCIPAL (Only)
SUPERINTENDENT APPROVAL:
DATE SIGNATURE OF APPROVAL BY SUPERINTENDENT