Field Trip Request - Castle Park High School

Field Trip Request - Castle Park High School

Castle Park High School ASB
1395 Hilltop Drive Chula Vista, CA 91911 (619) 585-2050
Memorandum
Date:
August 25, 2009
To:
Castle Park High Staff
From: Abram Jimenez, Assistant
Re:
Principal of Student Activities
Fieldtrip Policies and Procedures
Pursuant to Board Regulation 6415.1 (included in this packet for your review) the following
policies and procedures must be followed in order to be granted permission for a field trip off
campus. All applications must be first approved by the Principal then submitted to the ASB
Office.
Applications for one day, in-state field trips must include the following:
1. Field Trip request Form signed by the Principal
2. Copy of Parent Permission slip given to students
3. Student Roster
4. Student Eligibility To Be Excused From Class for each student
5. Bus Request
Applications for overnight trip, within state, no more than two nights:
1. All of the above
2. Short Term Insurance purchased for each student
3. Superintendent's
approval (allow for 30 days notice)
Application for overnight trip of more than two nights and/or out of state or country:
1. All of the above
2. Hold Harmless Agreement if personal funds or fundraised
(one for each student)
3. Board Approval (allow for 60 days notice)
All trips where personal vehicles are used to transport
sheet approved and on file with Risk Management.
students
monies used to pay for trip
must have a driver information
Sweetwater Union High School District programs and activities shall be free from discrimination
based on gender, sex, race,
color, religion, ancestry, national origin, ethnic group identification, marital or parental status, physical or mental disability,
sexual orientation or the perception of one or more of such characteristics. SUHSD Board, Policy 0410
"A Tradition Of Excellence "
SWEETWATER
UNION HIGH SCHOOL DISTRICT
CLASSIFICATION:
SUBJECT:
Excursions
RESPONSIBLE
OFFICE:
REFERENCES:
REGULATION:
Students
6145.1
and Field Trips
ADOPTED:
Feb., 1979
Student Support Services
REVISED:
Nov., 2006
Policy 6145; Regulations
6145.3, 6145.4
6145.2,
NEXT REVIEW: 2010
PAGE 1 OF 5
Excursions
and Field Trips are an integral part of the students'
educational experience.
Because of the inherent risks assumed by the
district
in authorizing
and conducting
these
excursions,
numerous
factors must be considered and addressed.
I.
Application
for Excursions
or Field Trips
A.
All applications for excursions and/or field trips shall be in
writing.
Form No. 7209-03 (see Exhibit 1) with addendum shall
be used for this purpose.
B.
Sequence of Application
Approval
1.
Certificated
employee sponsoring a proposed excursion or
field trip prepares an application and forwards it to the
principal.
2.
The
principal
approves
or disapproves.
If further
approval is required, the principal forwards the trip plan
to the superintendent or his/her designee.
If further
approval
is
required,
the
supe-rintendent or his/her
designee
forwards
the trip plan
to the board.
The
superintendent or his/her designee notifies the principal
of the action taken.
C.
Applications
constitute
planning
documents.
No
formal
announcement of the planned activity and fund-raising or other
implementing action shall be initiated until authorized by the
approving authority.
D.
Applications
shall be submitted early enough to aILow the
approving
authority
ample time to approve
or modify the
application in a manner that is fair to all concerned.
(See
Section II, Approval Authority} .
E.
In all instances, applications for excursions of field trips
shall include a statement of purpose in which the sponsor
establishes
objectives
for the proposed
field trip that
clearly
demonstrates
educational
value,
a full itinerary
including dates and sites of all activities in which students
will participate,
and evidence of compliance or assurance of
the ability to comply with the following:
1.
Execution and submission of assurance that public funds
will not be utilized for other than salaries of district
employees in conducting a trip, if out-of-state.
REGULATION
II.
NO:
PAGE 2 OF 5
6145.1
2.
If out-of-state, written assurance that all adults, and
the
parent(s)/guardian(s)/caregiver(s)
of all students
participating
in the field trip will execute a written
waiver of claims and hold harmless agreement, waiving all
claims against the district, its employees, and the State
of California
for injury, accident,
illness, or death
occurring during of by reason of the field trip.
3.
Provision
of
adequate
insurance
participating adults and students.
4.
Provision of assurance of sufficient funds to cover travel
and living expenses
for all participants
if trip is
outside of San Diego County.
5.
No student will be excluded from the field trip because of
lack of sufficient funds.
6.
Formulation of a plan for fund-raising activities (when
appropriate),
including methods
of accounting
for the
funds, paying expenses, and those unable to pay their own
expenses, and return of funds if not used for the purpose
specified by the contributors.
7.
Satisfactory
involved.
academic
make-up,
when
protection
school
absence
for
is
Approval. Authority
A.
B.
C.
One day field trip.
1.
The site principal has authority to approve.
2.
The application must be submitted at least ten school days
in advance of the planned trip.
Overnight trip, within
and three days.
the state, of no more
1.
The superintendent
approve.
or his/her
2.
The application
must be submitted
at least one month
(thirty calendar days) in advance of the planned trip.
Field trips involving
travel.
designee
than two nights
has
authority
to
three or more nights and/or out-of-state
1.
Only the board of trustees has authority
to approve.
2.
The application must be submitted at least two months
(sixty calendar days) in advance of the planned trip.
REGULATION NO:
III.
IV.
6145.1
PAGE 3 OF 5
Supervison
A.
All excursions and field trips shall be under the direct
supervision
of certificated
employees
of the district
in
accordance with district policies and regulations.
B.
A minimum of one adult supervisor per bus shall be provided.
For out of country
and overnight
excursions,
one adult
supervisor for each fifteen students shall be provided.
Insurance
The current school district liability insurance coverage includes
approved
excursions
and field trips.
In addition, district
employees
and non employee, adult volunteers
are covered by
worker's
compensation
for any accident
occurring
while such
persons are acting within the scope of their duties.
Students
are provided
limited accident
insurance
through the
district's student travel coverage policy for anyone-day
field
trip away from school for up to a $1,500.00 maximum benefit.
Students participating
in approved excursions
or field trips
extending beyond one day shall be required to purchase Short Term
(24)-Hour Coverage Student Accident Insurance.
Cost of such
insurance shall be included in the costs of the excursion or field
trip.
(Note: Special trip insurance may be purchased through the
regular student accident insurance program.
V•
Waiver of
CJ.aims
A.
District
employees
who
are
supervising
field
trips
or
excursions
taken
within
the
state
are
covered
by
the
district's insurance policy for accident, illness, or death
occurring during or by reason of the field trip or excursion.
B.
Parent(s)/guardian(s)/caregiver(s)
or other volunteers serving
in the role of chaperone on a field trip or excursion taken
within the state are deemed to have waived all claims against
the district or State of California for injury, accident,
illness, or death occurring during of by reason of the field
trip or excursion in accordance with Education Code Section
35330 (d).
C.
In the case of out-of-state field trips and excursions, all
adul ts
(including
district
employees
and
parent (s)/
guardian (s)/caregiver (s) or other volunteers
serving in the
role of chaperone or other status) shall sign a statement
waiving claims against the district or the State of California
for injury, accident, illness, or death occurring during or by
reason of the field trip or excursion in accordance with
Education Code Section 35330(d).
Parent Permission and Waiver of Claim, Form No. 7207-03 (See
Exhibi t 2), and Adult Participation Statement and Waiver of
Claim, Form No. 7208-03 (See Exhibit 3), shall be used for
this purpose.
REGULATION NO:
VI.
PAGE 4 OF 5
6145.1
Revocation of Authorization
Agreement not to Sue
and
Hold
Harmless
Agreement
and
In the event that the superintendent
determines
through the
process identified in Board Policy No. 6145, that there is either
a potential or real risk to students' health or safety, he/she has
the authority to make an immediate and decisive determination to
revoke the district's authorization for an excursion or field
trip.
As part of the protocol, the superintendent or his/her
designee shall contact the affected group (s) using information
provided
on
(Form 7209-03, Request for Excursion/Field
Trip;
Exhibit 1), to inform them of his/her intention.
In making his/her decision, the superintendent may solicit a
variety of sources, including parents, the u.s. State Department
Advisories, the Center for Disease Control Information, and the
Sweetwater Union High School District's General Counsel.
All parties traveling on an excursion or
expended either their own
ersonal funds or fundrai .
es
mus
sign and submit a Hold Harmless Agreement and Agreement Not
to Sue Regarding District Authorization (Form No. 4020-03, Exhibit
5) with their application for excursions and field trips.
The
purpose of the hold harmless agreement is the acknowledgment by
the participant
that they will assume all financial risk for
personal or fundraising funds and that the district assumes no
financial liability as a result of the revocation.
VII.
Budget ~location
All site and district-funded excursions
planned and implemented wi thin budget
funded by the district may be authorized
field trips assure fulfillment of all
Section IT Application for Excursions or
and field trips are to be
allocations.
Trips not
provided sponsors of such
conditions stipulated in
Field Trips.
VIII. Financing
Plans for financing excursions of field trips and related fund
raising activities shall be submitted to the approving authority
prior
to
implementation.
Plans
shall
meet
all
criteria
established in related board policy and regulations, including
provisions for paying all or part of the expenses of those who
would be unable to meet expenses without assistance.
IX.
Expenses
A.
If the excursion or field trip is conducted in part during the
regular school day, salaries of employees of the district
shall be paid.
B.
Expenses may be paid from regular funds, including incidental
expenses
for use of school district equipment during the
excursion or field trip.
C.
No
expenses
of
students
participating
in
the
field
trip
or
REGULATION NO:
6145.1
PAGE 5 OF 5
excursion to any other state, the District of Columbia, or a
foreign country shall be paid with school district funds;
however:
1.
Expenses
(including transportation, meals, and lodging)
for
staff
and
other personnel
who
supervise
and/or
chaperone student field trips or excursions out of state
may be paid by the district, or the student organization
and/or the booster group involved.
2.
District
funds may be used for expenses
involved in
support of school equipment utilized during an authorized
excursion of field trip.
Employees may contribute their services over and above the normal
period for which they are employed by the district if necessary to
conduct a particular excursion or field trip.
x.
Food Service
Students may request sack lunches for field trips.
Cafeteria
shall be provided list of students requesting lunches 10 days
prior to event. Student Personal Identification Numbers (PIN's)
shall also be provided.
Meals are available at no cost to
students who qualify. Cash shall be collected for those students
who are not participating on the meal program.
XI.
Transportation
Where
time and distance
permit,
transportation
shall be by
district-owned
and district-operated
buses.
Where this is not
feasible,
commercial
carriers
shall be used.
Criteria
for
selection and the use of such carriers shall be in accordance with
board
policy
and
regulations
regarding
use
of
commercial
transportation.
When numbers of students involved, and time/distance factors make
district or commercial buses impractical and/or uneconomical, the
approving authority may authorize use of private vehicles for
transportation.
Where
private
vehicles
are
used
for
transportation,
for approved
excursions
or field trips, the
insurance
coverage of the privately
owned Vehicles
shall be
considered primary.
(Exhibit 4)
Students, including those over 18 years of age are prohibited
transporting other students.
XII.
from
ADA for Field Trips
Credited attendance resulting from a field trip shall be limited
to the amount of attendance that would have accrued had the
students not been engaged in the field trip, but shall not exceed
ten school days.
SWEETWATER UNION men SCHOOL DISTRICT
REQUEST FOR EXCURSIONIFIELD TRIP
Date
SCHOOL
______________________________
---------------------
~DEPARTMENT
Trip Information
1.
Sponsoring agency/group
_
2.
In the event of a potential Revocation of District Authorization for Excursion/Field Trip, the following are the two key
contacts the Superintendent and/or his designee may direct all correspondence to:
Name:
Hm. #
WK. #
Email
Name:
Hm. #
WK. #
Email -----------
3.
Destination (Attach itinerary if more than one stopover is involved)
4.
Expected day/time of departure
5.
Number of overnight stays
Comment
6.
Number of days of travel
Comment
7.
Expected day/time of return
8.
Purpose (Goals/objectives with clear indication of relationship of the proposed field trip to the district course of study.
Attach separate sheet if necessary)
9. .
Certificated staff member responsible
_
_
10.
Number of participants (Less adult chaperones)
11.
Number of adult chaperones, less certificated staff member responsible
12.
Transportation will be provided by:
District bus
0 Commercial carrier (Charter Bus)
0 Private vehicle*
*If using a private vehicle, please complete Driver Information Sheet (Form 4124-03, Exhibit 4) and submit to the
Office of Fiscal Services.
13.
If by commercial carrier*, the company providing transportation:
*You may only use a commercial carrier that has been approved by the board of trustees.
o
Projected costs: TO=.t;;;::a:.;..1 _
14.
Per participant
Insurance:
Health Insurance:
Policy Number
Student Accident Insurance: Amt. of Coverage $
15.
16.
I.
---------Carrier
Carrier
Funding Source
(Le. Cat.lGrant.)
----------------------------
--------------------------
The following has been complied with or will be complied with prior to departure:
For one-day excursion/field
trips, principal's approval required; (please complete the following)
a.
Parent permission slip for student participation on file exempting the district from all financial
responsibility.
o
o
b.
Adequate optional illness, accident and death insurance provided for all participating students and adults.
(Supplemental
insurance.)
II.
Health/Accident Insurance available for a nominal fee through provider of student accident
o
c.
If out of country, written assurance of sufficient funds to cover all travel and expenses, executed and filed.
o
d.
Written assurance that no student will be excluded from excursion or field trip because of lack of sufficient
funds.
o
e.
If absence from school is involved, plan for academic make-up formulated and filed with the principal(s).
Copy of make-up plan attached.
For two-days overnight excursionlfield trips, Board of Trustees approval required; (please complete the
following)
a.
Parent permission slip for student participation and Hold Harmless Agreement & Agreement Not to
Sue Re: Revocation of District Authorization on file exempting the district from all financial
responsibility.
o
o
b.
If out-of-state, statement specifying public funds will not be utilized for anything other than salaries,
executed and filed.
o
c.
If out-of-state, waiver of claims and hold harmless agreements executed by each adult and parent or
guardian of each student participating in the field trip, and filed.
o
d.
Adequate optional illness, accident and death insurance provided for all participating students and
parents.
(Supplemental Accident Insurance available for a nominal fee through provider of student
accident insurance.)
0
e.
Required liability insurance provided when using private vehicle and commercial carrier.
0
f.
If out-of-country, assurance of sufficient funds to cover all travel and living expenses, executed and filed.
0
g.
Assurance that no student will be excluded from excursion or field trip because of lack of sufficient funds,
executed and filed.
0
h.
If out-of-state, assurance that sufficient "cancellation" insurance has been investigated and Hold
Harmless Agreement & Agreement Not to Sue Re: Revocation of District Authorization (Form No.
4020-03) is on file exempting the district from all financial responsibility in the event the activity is
cancelled.
o
i.
If absence from school is involved, plan for academic make-up formulated and filed with the principal(s).
Copy of make-up plan attached.
o
j.
If appropriate, fund-raising plans, including methods of accounting for funds, paying expenses of those
unable to pay their own, and returning monies not used for the purpose specified by contributions,
formulated. Copy of fund-raising plans attached.
Person proposing excursion/field trip
Principal
Additional authority, of other than principal
Form No. 7209-03
Exhibit 1
Exhibit 2
SWEETWATER UNION HIGH SCHOOL DISTRICT
PARENT PERMISSION FOR STUDENT PARTICIPATION IN OFF-CAMPUS SCHOOL-SPONSORED
Name:
~_,
EVENTS
has my permission to attend
which will take place at
---:-
_
(activitylEvent)
Date of event:
__________
Class or group attending
_
Method of transportation
1.
2.
Return time:
Depart time:
_
_
Teacher/leader
If traveling by automobile,
Name of driverlDrivers
License #
_
D.L. #
_
o
I understand that all students going on this trip will be responsible in conduct to the bus driver, to
teachers or adult sponsors. It is further understood that students will go and return from the event
on the transportation provided and that every reasonable caution will be maintained on the trip.
o
I hereby acknowledge
trip or event are
participants.
that I have been advised that the activities involved in this excursion/field
are not
considered by the district to be of "high risk" to the
Education Code §35330 provides as follows:
"All persons making the field trip or excursion shall be deemed to have waived all claims against the
district or the State of California for injury, accident, illness, or death occurring during or by reason of the
field trip or excursion. All adults taking out-of-state field trips or excursions and all parents or guardians of
pupils taking out-of-state field trips or excursions shall sign a statement waiving such claims."
In accordance with this statute, and in consideration of my son/daughter's
participation in said field trip
or excursion, I hereby release the Sweetwater Union High School District, its officers, employees and
agents from and waive all claims for injury, accident, illness, death or property damage occurring during or
by reason of said field trip or excursion, and arising from any cause whatsoever, including illegal acts of
third parties, terrorism, or act or war, except for any claims based upon the fraud, willful injury to
person pr property, or violation oflaw by the District, its officers, employees and agents, and further agree
to indemnify and hold harmless the District, its officers, employees and agents from any claims and actions
for damage or injury which any person may assert by reason of my son/daughter's
conduct while
participating in said field trip or excursion.
Cold sack lunches are available from the school cafeteria
no cost. All others must purchase or bring lunch.
Students who qualify may receive meals at
In the event of any of any illness or injury to my son/daughter, I hereby consent to whatever x-ray,
examination, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care from a licensed
physician and/or surgeon as deemed necessary for my son/daughter's
safety and welfare. I agree that the
resulting expenses will be my responsibility.
DDD-DDD-DDDD
Signature
of Parenti Guardian
Health Insurance Company
Cellular telephone # to contact
Parent or Guardian during event
Date
Policy Number
Exhibit 2
CONSENTIMIENTO
SWEETWATER UNION HIGH SCHOOL DIS1RICT
DE LOS PADRES PARA PARTICIP ACION DEL ALUMNO(A) EN EVENTOS FUERA
DE LA ESCUELA PATROCINADOS POR LA ESCUELA
Nombre:
, tiene mi permiso para asistir/participar en
Que tendra lugar en
_
(actividadlevento)
Hora de salida:
Fecha del evento:
Clase
0
grupo que asistira:
Metodo de transporte:
Hora de regreso:
Maestro/encargado
_
Si viaja por automovil,
Nombre del chofer(es) y
mimero de licencia
_
D.L. #
_
1.
0
Entiendo que todos los alumnos que van en este viaje, responderan de su conducta al chofer del
autobus, maestro 0 patrocinadores adultos. Ademas, entiendo que los alumnos iran al evento y
regresaran del rnismo en el transporte proporcionado, y que durante el viaje, se tomaran todas las
precauciones necesarias.
2.
0
Reconozco que se me ha informado que el distrito considera que las actividades del evento, viaje,
paseo 0 excursion. en que participara el alumno( a) son
no son
de "alto
riesgo" para el participante.
EI C6digo de Educaci6n §35330 provee 10 siguiente:
"Se considera que todas la personas participantes en este viaje, paseo 0 excursion renuncian a toda demanda
en contra del distrito 0 del Estado de California por lesiones, accidente, enfermedad 0 muerte que ocurriese
durante 0 debido al viaje, paseo 0 excursion. Todo adulto que participe en viajes, paseos 0 excursiones fuera del
estado, y todos los padres 0 tutores de alumnos participantes en viajes, paseos 0 excursiones fuera del estado,
firmaran una declaracion de renuncia a dichas demandas."
De acuerdo a este estatuto, y en consideracion de la participacion de rni hijo(a) en dicho paseo, viaje 0
excursion, yo libero de toda responsabilidad al Sweetwater Union High School District, sus oficiales, empleados y
agentes, y renuncio a toda demanda por lesiones, accidente, enfermedad, muerte 0 daiios a propiedad que ocurran
durante 0 por razon del paseo, viaje 0 excursion, y que surjan de cualguier causa, incluyendo actos i1egales de
terceros, terrorismo 0 actos de guerra, excepto de toda demanda basada en fraude, lesiones 0 dafios intencional
a persona(s) 0 propiedad, 0 por violacion a las leyes por el distrito, sus empleados y agentes; ademas estoy de
acuerdo en indemnizar y liberar de responsabilidad al Distrito, sus oficiales, empleados y agentes de toda
demanda y accion por daiios 0 lesiones que cualquier persona podria afirmar por razon de la conducta de rni
bijo(a) durante su participaci6n en dicho viaje, paseo 0 excursion.
La cafeteria de la escuela tendra cornidas mas disponibles.
alguno. Los demas alumnos podran comprar 0 traer su cornida.
Alurnnos que califiquen, las recibiran sin costo
En caso que mi hijo(a) se lesionara 0 enfermara, otorgo mi consentirniento para que reciba la atenci6n medica
necesarla (radiografias, examen, anestesia, tratarniento medico, dental 0 diagnostico para cirugia y hospitalizaci6n
por parte de un medico 0 cirujano con licencia para practicar su profesion, segun se considere necesario para le
seguridad y bienestar de mi hijo(a). Estoy de acuerdo in responsabilizarme de los gastos surgidos.
ODD-ODD-DODD
Firma del padre
0
tutor
Nombre de la compaftia del seguro de salud
Telefono Celular para localizar a
Padre 0 tutor durante el evento
Fecha
Numero de la paliza
SWEETWATER
UNION HIGH SCHOOL DISTRICT STATEMENT
REGARDING ADULT PARTICIPATION IN OFF-CAMPUS
SCHOOL-SPONSORED EVENTS
I, ____________________
in
___________
-'- __
plan to participate
-=_--:-----:--::--::--:--
-1.'
and do hereby
(Event or Activity)
acknowledge that I have been advised that the activities involved in this excursionlfield trip or
event are __
are not __
considered by the district as being of "high risk" to both
student and participants.
(Signature)
(Date)
WAIVER OF CLAIM
(To Be Completed for Out-of-State Events Only)
I do hereby waive all claims and hold harmless the individual sponsors, the Sweetwater Union
High School District, and the State of California for any injury, accident, illness, death, or any
loss or damage to personal property occurring during or by reason of this excursion/field trip or
event.
(Date)
Form No. 7208-03
(Signature)
Exhibit 3
SWEETWATER UNION HIGH SCHOOL DISTRICT
DRIVER INFORMATION SHEET
(To be filled out by persons who will be driving private vehicles to transport students on
excursions, field trips, or extracurricular events.)
, will be driving a private
I,
vehicle used to transport students from
(School Site)
on an excursion/field trip or extracurricular event, to:
on
(Date)
(Place)
I certify that:
A.
I possess a current, valid, driver's license,
No.:
B.
I carry a minimum insurance of $100,000 bodily injure per person/$300,000 per
accident and $50,000 property damage, or in lieu thereof, $300,000 combined
single limit.
Carrier:
C.
The vehicle I will be driving is in safe condition and will not be overloaded for the
trip.
D.
You will need to provide a copy of:
1. Your driver's license; and
2. Your current insurance declaration sheet which lists your coverage.
(Signature)
Form No. 4124-03 (Fiscal Services)
(Date)
Exhibit 4
SWEETWATER UNION HIGH SCHOOL DISTRICT
Hold Harmless Agreement and Agreement Not to Sue
Regarding Revocation of DistrictAuthorization
I, the undersigned, declare that it is my desire to allow my child(ren),
_________________________
t
excursion or field trip to
~. on
to participate in the planned
---'
'
I am aware that it is possible that the District authorization for the planned excursion or field trip
may be revoked or withdrawn at the discretion of the Superintendent due to concerns for student safety or
other circumstances or events.
I understand that a cancellation may occur even after all required deposits have been paid and all
arrangements have been made. I understand that the Sweetwater Union High School District recommends
that I investigate travel cancellation insurance and I understand that it is my responsibility to do so.
In the event of a revocation, I am aware that the Sweetwater Union High School District, its board
members, officers and employees would not be responsible for reimbursing any money to me or any other
person or entity who has contributed money or time to fund my child(ren) costs for the planned excursion or
field trip.
In exchange for the right to register my child(ren) to participate in the planned excursion or field trip
identified above, I hereby agree that I, my heirs, legal representatives and assigns do release, discharge and
will hold harmless and not sue the Sweetwater Union High School District, its officials, employees,
representatives, agents, servants or volunteers, for any liability, claims, damages, expenses, actions or costs
suffered by me in raising, giving, granting, loaning or donating funds or items to support the participation of
my child(ren) in the excursion of field trip. I also agree to indemnify the Sweetwater Union High School
District for claims by any person or entity arising from their participation in a fundraising or giving,
granting, loaning or donating funds or items to support the participation of my child(ren) in the excursion or
field trip.
I HAVE CAREFULLY READ THIS HOLD HARMLESS AGREEMENT AND AGREEMENT
NOT TO SUE AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE TIIAT IT IS A FULL
RELEASE OF ALL RIGHT TO DEMAND REIMBURSEMENT OR SUE IN CONNECTION WITH
EXPENSES INCURRED OR FUNDS RAISED IN CONNECTION WITH THE PLANNED EXCURSION
OR FIELD TRIP IDENTIFIED ABOVE. I SIGN IT OF MY OWN FREE WILL.
Print Name Mother:
_
Print Name Father:
_
Signature:
_
Signature:
_
Address:
_
(Street)
Date:
Form No. 4220-03 (Fiscal Services)
(City)
_
Home Phone:
(State)
(Zip)
_
ExhibitS
SWEETWATER UNION HIGH SCHOOL DISTRICT
Acuerdo de Liberacion de Responsabilidad y de No Demandar
Sobre Ias Revocacion de la autorizacion del distrito
Yo,
paseo
dia
o
el
subscrita,
excursi6n
de
que
declaro
se
tiene
que
es mi
planeado
de
deseo
permitir
a mi
a
hijo(a) a hijos(a) ,
participar
en el
el
Estoy cansciente que sea posible que la autorizaci6n del Distrito para el paseo
a excue i.on planeada puede ser revocada a retirada a d.iscxec.ion del Superintendente,
debido a inquietudes
par la seguridad del alumna (a) a alumnas 0 ambos, 0 debido a
otras circunstancias
a eventos.
Entiendo que a pesar que se hayan hecho 0 pagado todos los depositos requeridos
y hecho todas los arreglos necesarios, puede suceder que se cancele.
Entiendo que el
Sweetwater
union High School District recomienda que investigue acerca de un segura
sabre cancelacion de viajes y entiendo que es mi responsabilidad hacerlo.
En caso de una revocaci6n, estoy consciente que el Sweetwater Union High School
District,
sus miembros del consejo
(board members) oficiales y emp1eados no serian
responsab1es
de reernbolsarme ningun dinero a mi a a cualquier otra persona a entidad
que haya contribuido
dinero,
tiempo para patrocinar
e1 costa de a mi hijo(a) a
hijas(as)para
1a excursion a viaje p1aneado.
A cambia del derecho de inscribir a mi hijo(a), hijos(as)para que participen el
la excusion a viaje que se planea y que se identifica arriba, estoy de acuerdo que Yo,
mis herederos,
representantes
legales, asignados y demas liberamos, finiquitamos
y
liberamos y no demandaremos
al Sweetwater Union High School District, sus oficiales,
empleados,
representantes,
agentes,
sirvientes
a
voluntarios,
par
ninguna
responsabilidad,
reclamo, danos y perjuicios, gastos, acciones a costas sufridos par
mi en reunir,
dar, permitir,
prestar
a donar fondos,
articulos
para apoyar la
participacion
de mis hijos(as) en la excursi6n, viaje a paseo.
Estoy de acuerdo en
indemnizar al Sweetwater Union High School District por demandas de cualquier persona
a entidad que provenga de su paz-tLc Lpacd on en la campana para reunir fondos, dar,
prestar
a donar fandos a articulos para apoyar la par-ti.cf.pacf.on
de mi hij a (a) 0
hijos(as) en la excursion a paseo a viaje.
HE LEIDO CUIDADOSAMENTE
ESTE ACUERDO DE LIBERACION DE RESPONSABILIDAD
Y ACUERDO DE NO
DEMANDAR
Y ENTIENDO
COMPLETAMENTE
SU CONTENIDO.
ESTOY
CONSCIENTE
QUE ES UNA
LIBERACIoN
COMPLETA DE TO DO DERECHO DE DEMANDAR REEMBOLSO 0 DE DEMANDAR EN RELACIoN
CON LOS GASTOS CONTRAIDOS 0 FUNDOS REUNIDOS EN CONEXION CON LA EXCUSION, VIAJE 0 PASEO
PLANEADO E IDENTIFICADO ARRIBA.
FIRME POR PROPIA VOLUNTAD.
Use letra de molde, Nombre de la madre:
_________________
Firma:
_
Use letra de molde, Nombre de la madre:
_________________
Firma:
_
Domicilio:
Ciudad
Calle
Fecha:
_
Numero de telefono de la casa:
Estado
Z.P.
_
SHORT-TERM (24-HOUR) COVERAGE
Enrollment Form 2007-2008 School Year
100% Participation Required
myers. stevens
Provides excess accident and emergency sickness medical coverage and accidental death and dismemberment coverage for all students
participating in school sponsored and supervised activities involving overnight travel and/or periods without direct and immediate
school supervision. Rate is $1.60/person/calendar
day. Coverage consists of BASIC and CATASTROPIDC injury benefits.
BASIC accident medical benefits are paid on an excess basis at 100% of Usual, Reasonable & Customary charges up to $25,000/injury
and up to $500 for Emergency Sickness (not applicable in KS). Includes benefit for pre-approved Medical Evacuation expenses up to
$25,000 and up to $10,000 of expenses for Repatriation of Remains to home country. Covered charges for injuries are limited to those
incurred within one year from date of first treatment and Emergency Sickness benefits are limited to those charges incurred within 24
hours from the onset of sickness. The policy has complete details of provisions, limits and exclusions. Underwritten by BCS
Insurance Company in the states of AZ, CA, KS, MO and NV and by ACE American Insurance Company in all other states.
CATASTROPIDC
accident medical benefits are subject to a deductible of $25,000 and are then paid at 100% of Reasonable and
Customary Charges up to $1,000,000. Includes additional cash benefits of up to $500,000 (depending upon the severity of the loss)
and accidental death benefit of $25,000. Underwritten by ACE American Insurance Company.
FORM AND LIST OF NAMES MUST BE RECEIVED BY MYERS-STEVENS PRIOR TO THE START DATE OF
ACTIVITIES, OTHERWISE COVERAGE WILL BEGIN UPON RECEIPT.
Please complete the entire form, attach list of names, and return with your premium or billing information to:
Myers-Stevens & Toohey & Co., Inc., 26101 Marguerite Parkway, Mission Viejo, CA 92692-3203
(949) 348-0656 or (800) 827-4695, fax number (949) 348-0963 or (949) 348-2630
It is required that all students attending the event be covered, whether they have other insurance or not.
This plan does not cover paid school employees. (Coverage is optional for Parent chaperones; include names with list of students).
DISTRICT:
SCHOOL:
____________________________
~PHONE#:(
)----------------
ADDRESS:
From:
DATE(S):
To:
_
DESTINATION/ACTnnTY:
_
PLEASE NOTE: THERE IS A $35.00 MINIMUM PREMIUM REQUIREMENT.
Premium is due prior to the start date of activity
Calculate Premium Due:
x
# of Participants
Coverage
Requested By:
x
# of Calendar Days
-:---::Print Name
$1.60
Premium Rate
PREMIUM DUE ($35 minimum)
Ifpaying by MCNisa, please
complete section below.
Signature:
_
METHOD OF PAYMENT: (please do not send cash).
MCNlSA AUTHORIZATION: MC:__
P.O. NUMBER
CHECKNUMBER:
Vol Rev 04-06
VISA:
_
EXP. DATE:_I_
Zip code of card holder
AMOUNT OF CHECK:
CA License #0425842
Card holders signature
NAME ON CHECK:,
_
All States S.T. 24-HR
STUDENT ELIGIBILITY TO BE EXCUSED FROM CLASS
Student's
Name
_
Grade
Please indicate whether the above named student is doing sufficiently
for this event. Any "NO" reply invalidates this request.
SUBJECT
PERIOD.
_
Oate
_
well in your class to be excused
YES
TEACHER SIGNATURE
.
NO
STUDENT ELIGIBILITY TO BE EXCUSED FROM CLASS
Student's
Name
_
Grade
Please indicate whether the above named student is doing sufficiently
for this event. Any "NO" reply invalidates this request.
SUBJECT
PERIOD.
_
Oate
_
well in your class to be excused
TEACHER SIGNATURE
YES
.
NO
STUDENT ELIGIBILITY TO BE EXCUSED FROM CLASS
Student's
Name
_
Grade
Please indicate whether the above named student is doing sufficiently
for this event. Any "NO" reply invalidates this request.
PERIOD.
SUBJECT
TEACHER SIGNATURE
_
Oate
_
well in your class to be excused
YES
.
NO
:-
~~.
---
Castle Park High School
APPLICATION FOR BUS TRANSPORTATION
Date Submitted
Please complete this form for each bus needed (one bus for 75 students) and return it to
the Dean of Activities. Requisitions MUST be processed so as to reach the District
Transportation Office not later than ten (10) working days before the date the bus is
needed.
1.
Teacher/Coach Making Request
2.
Day of Week Bus is Needed
Date Bus is Needed
3.
Specific Event
4.
Starting Time of Event Students are Attending
5.
Pickup Point
6.
Destination
7.
Students Should Arrive at Destination
8.
Students Will Be Loaded on Bus for Return Trip
9.
How Many Students Are Going to be Attending
10.
Total Number of Buses Requested for Trip
11.
Will you need this bus for transportation during the field trip?
12.
Teacher Who Will Ride This Bus
13.
Does the Principal Know/Approve of this Trip
14.
Athletics
(a.m. or p.m.)
(a.m. or p.m.)
(a.m. or p.m.)
Music
Educational Field Trip
15..
This.trlp.wlll.be.paid for by:
Budget#
16.
Yes / No
ASB
Site
(circle
Yes / No
District
one)
_
ASB
District
I am familiar with the provisions of District Bulletin #201 and have read the rules
extracted
from this. bulletin on the back of this sheet.
.
Teacher /Coach Signature
SUBJECT:
BULLETIN NO.:
APPROVED SPECIAL BUS TRIPS
201
Page 6 of 6
ISSUE OR REVISION DATE:
September 12, 1972
BUS TRANSPORTATION
INSTRUCTIONS TO TEACHERS FOR SPECIAL BUS TRIPS
Teachers have the following responsibilities for Special Bus Trips:
1.
Submit request for use of school bus two weeks prior to the trip by filing with the school
office a requisition form completely filled out.
2.
Insure that "Parent Permission Slips" are properly filled out and signed before start of
trip.
3.
Make sure there is always a teacher on each bus on special trips.
4.
Inform the principal regarding classes from which he will be absent and for which a
substitute will be needed.
-
5.
Identify himself/herself to the driver as the certificated bus rider, and aiso confirm the
loading point and the time of departure.
6.
Confer with the driver regarding the route to be followed, prior to the departure of the bus.
7.
Possess a written list of the students on the bus and any equipment involved.
8.
Notify the driver when the students and equipment are loaded and the bus is ready to
leave.
9.
Cooperate with the bus driver on special regulations, such as: no cleats on shoes; opening
of windows, no eating.
10.
Maintain reasonable order arid discipline on the bus. It should be realized that the 'driver
is responsible for the safety of pupils and his bus, and the teacher should therefore listen
to suggestions the driver might "make as to the type of conduct to be maintained. This
might vary due to driving conditions, traffic problems, weather, and drivers.
The following types of conduct are never permissible:
Loud noises such as shouting.
Hitting/slapping one another (even in jest).
Amorous demonstrations.
Smoking.
Throwing things.
Moving about the bus.
-II.
Instruct thestudents.as tothe location and time for reloading for the return trip and check
the roll. All students must return
the-bus-uriTes-s-a"peison-arrequ-e-stis-made--by-a - "- -parent that a pupil bereJeased from returning by bus.
on