SIZER FIELD TRIP REQUEST & PLANNING FORMS FIELD TRIP REQUEST & PLANNING FORMS 500 Rindge Road, Fitchburg, MA 01420 • School Phone: 978-345-2701 • Fax: 978-345-9127 Page 3 of 4

SIZER FIELD TRIP REQUEST & PLANNING FORMS

500 Rindge Road, Fitchburg, MA 01420 • School Phone: 978-345-2701 • Fax: 978-345-9127 Page 1 of 4

Please note: It is the Lead Teacher’s responsibility to make sure all items in PHASE ONE,

PHASE TWO, and PHASE THREE on this request form have been completed prior to any

off grounds activity. The Lead Teacher is the person initiating the field trip.

Lead Teacher______________________________Group Attending_____________________

Destination____________________________Date of trip______________________________

PHASE ONE – APPROVAL

Please obtain initials from Principal of Instruction, Nurse, and Business Assistant

______See Principal for approval on all following points (Principal’s initials below) Concept Check____ Calendar Check____ Preliminary Budget Approval___ Final Budget Approval____ Inclusion Check____ (Behavioral___ Physical ___ Financial___)

______See Business Assistant with completed bus request form and budget form

(see Appendix).

□ Prepare separate requisitions for each expense that will be incurred (i.e. – First Student for bus, Boston Museum of Science for museum admissions, etc.). These must be signed by your department head and the Principal before being submitted to the Business Assistant. If you are expecting to incur out-of-pocket expenses, an expense report with an estimated dollar amount also must be approved and signed by the Principal prior to the trip.

______See School Nurse for completion of the following: (Nurse’s initials and comments below)

o Will all students in the group be able to attend and participate? Yes_________ No__________

o Will a nurse be required on this trip? Yes___________No_____________ o Please note any specific medical coverage requirements needed for the

trip:_____________________________________________________________________________________________________________________________________________________________________________

PHASE TWO – PLANNING/PREP

□ If necessary, prepare a plan for non-attending students. Field trips ARE the curriculum of the day and arrangements should be made to include ALL students. If for some reason an alternative plan must be made, this plan must be finalized 1 week prior to the date of the trip. This plan needs to include discussions with team leaders, etc. to determine where non-attending students should be assigned.



□ Check in with appropriate school counselor to see if additional planning is needed for students with emotional needs. If additional accommodations are needed for certain students, please make sure to communicate these with the field trip leader, student, parents, and appropriate chaperones.

□ Make any needed reservations for group tours, theater seating, etc.

□ Inform Lunch Coordinator of students missing a scheduled school based meal or if you will need brown bag breakfasts or lunches for the trip at least 2 weeks prior.

□ Prepare permission slips. The standard slip is available at the end of this guide and on the public drive in the Employee Resource folder and can be filled in with specific information for your trip. A note to the parents and students should be included outlining any special pick up/drop off procedures, equipment/supplies/lunch needed, payment/permission slip procedure with a deadline, and information for parents regarding confidential financial assistance available for those students who receive free/reduced lunch.

o If students will be driven in a personal vehicle, please refer to and follow all guidelines as outlined in Policy P6005.1.

o All permission slips and payments are to be turned in to the front office where they will be labeled with the students’ names and put in the Business Assistant’s mailbox for posting. The Business Assistant will keep a record of all permission slips and payments on a spreadsheet and send updated information to the Lead Teacher on a regular basis before the date of the trip. Permission slips will be held by the Business Assistant until the day before the trip at which time they will be turned over to the Lead Teacher. Teachers are responsible to notify any student that owes payment to submit that payment prior to the trip.

o All payments and permission slips must be collected three days prior to the trip. No student will be allowed on a trip without WRITTEN parent/guardian consent. Verbal consent will not be accepted.


□ Overnight trips require a Parent Info Meeting to include the following:

o Details of the trip o Clear outline for behavior expectations and discipline o Specifics of faculty supervision on the trip o Medical and physical requirements o Equipment to bring o Signed Behavior Contract o Permission Forms



□ Confirm Chaperones – 2 weeks ahead of trip, confirm number of chaperones needed, availability, any special training needed and CORI form needed.

□ Prepare Lists – Attending Students (Business Assistant’s worksheet), Bus Assignments, Tour/Chaperone Groups, Non-attending Students and their assignments.

□ Notify front office of students attending trip, students staying at school, any substitute coverage needed, etc.

□ Notify other teachers if students will be absent from their classes 2 weeks in advance.

□ Notify participating students that they are responsible for all missed work/assignments that occur on the day of the field trip. Meet with students to review expectations.

□ Prepare a “Trip Kit”. The kit should include the following: o First Aid Kit picked up from Nurse o Cell phones o Bus/chaperone lists o Signed permission slips and medical forms o Special equipment, including medical supplies

□ Submit a packet of all communications with students and parents regarding the trip, itineraries, lists, etc. to the Principal of Instruction.

PHASE THREE – DAY OF TRIP

□ Provide chaperone cell phone numbers to the front office.

□ Provide accurate attendance list to front office. The roster sheet from the Business Assistant can be used for this.

□ Lead teacher brings “Trip Kit”

□ Provide group lists to chaperones.

□ Take attendance before initial departure of bus and frequently throughout the trip. Always take attendance when re-boarding the bus. *Notify NCCES immediately if there is a vehicular accident, missing student(s), injury or any major violation of school rules while on a trip. NCCES: 978-345-2701 or Tricia May 978-790-6411 or Carey Doucette 617-335-2008.



□ Collect receipts. Please retain any receipts you are given throughout the trip to be submitted to the Business Assistant for accounting records.

□ Record Discipline and Accidents

□ Record mileage to and from trip location if driving. PHASE FOUR – AFTER TRIP

□ Prepare a trip report and submit it to the Principal. This is due within 2 business days. All disciplinary issues should be reported immediately. Was it a successful trip? Do you have suggestions for future trips? Were there any discipline problems? Accidents?

□ Return any borrowed equipment

□ Submit receipts to the Business Assistant for reimbursement. Explanation/Calculations TOTALS

Bus Fees

Admission Fees

Additional Charges +10% Contingency

Grand Total

Total Expenses divided by # of students = Price Per Student $_____________ ÷ # of Students___________ = $____________per student

OVERNIGHT FIELD TRIP PERMISSION AND RELEASE AGREEMENT

500 Rindge Road, Fitchburg, MA 01420 • School Phone: 978-345-2701 • Fax: 978-345-9127 1 of 3

Please read the entire form. If there is anything about this form or the described activity that you do not

understand, do not sign the form until you are satisfied that you have obtained a complete explanation. Fill in all

the blanks. If you have more than one child participating, please complete one form per child.

Please return this completed form to ________________________________________ by _______________________.

Field Trip Information:

Trip to: _______________________________________ Time leaving school: _____________________

Food: ______________________ Travel by: _____________ Time returning to school: __________________

Dates of trip: __________________ Cost of trip: ___________________

Special notes: (clothing needed, etc.)____________________________________________

Parent Permission & Release Form:

I, _____________________________________, the parent or guardian of ______________________________________, (parent/guardian name) (student name)

a minor, give permission for my child to participate in the activity described above. I/We do hereby consent to my child’s participation in voluntary athletic, recreational

programs or extracurricular activities of the Sizer School.

I/We also agree to forever RELEASE the Sizer School, a municipal corporation of the

Commonwealth of Massachusetts, and all their employees, officers, agents, board members,

volunteers and any and all individuals and organizations assisting or participating in voluntary

athletic, recreational programs or extra-curricular activities in the Sizer School (“the

Releasees”) from any and all claims, actions, rights of action and causes of action, damages,

costs, loss of service, expenses, compensation and attorney’s fees that may have arisen in the

past, or may arise in the future, directly or indirectly, from known and/or unknown personal

injuries to my child or property damage resulting from my child’s participation in the said Sizer

School voluntary athletic, recreational program or extra-curricular activity which I/we may

now of hereafter have as parents(s) of guardian(s) of said minor and which said minor child has

or hereafter may acquire, either before or after reaching majority.

I/We also promise to INDEMNIFY, REIMBURSE, DEFEND and HOLD HARMLESS the Releasees

against any and all legal claims and proceedings of any description that may have been asserted



in the past, or may be asserted in the future, directly or indirectly, including damages, costs and

attorney’s fees, arising from personal injuries to my child or property damage resulting from

my child’s participation in the Sizer School’s voluntary athletic, recreational programs or extra-

curricular activities or administration of first aid. I/We understand that a registered nurse will

not attend the field trip unless specifically stated. If I/We have medical/health concerns for our

child related to said activity, I/We will contact the health office to discuss them prior to the day

of said activity.

I/We further affirm that I/we have read this Consent, Release from Liability and Indemnity

Agreement, and that I/we understand the contents of this agreement. I/We understand that my

child’s participation in these programs is voluntary and that my child and I/we are free to

choose not to participate in said programs. By signing this agreement, I/we affirm that I/we

have decided to allow my child to participate in the Sizer School’s athletic, recreational

programs and extra-curricular activities with full knowledge that the Releasees will not be

liable to anyone for personal injuries and/or property damage my child or I/we may suffer in

the voluntary Sizer School’s athletic, recreational, programs or extra-curricular activities.

In witness whereof, have signed this document on the ______ day of _________________, 20___.

____________________________________________________________

Address

____________________________________________________________

Address

_______________________________________

Telephone Number

____________________________________________________ ____________________________________________________

Parent/Guardian Signature Student/Signature

School Nurse: E. Myriah Zwicker, R.N. – 978-345-2701 x 423, [email protected]



Student Health Information Sheet

Instructions: Please complete ALL sections as accurately as possible. This information

will be provided to the doctor or medical personnel to whom your child is taken in the

event of a medical emergency while on the school sponsored or school endorsed field trip.

Student Name: ____________________________________________________________________________________

Home Address: ___________________________________________________________________________________

Telephone Number: _______________________________ Date of Birth: ______________________________

Emergency Contacts:

Parent/Guardian1:____________________________________ Telephone: _______________________

Parent/Guardian2:____________________________________ Telephone: _______________________

Other Contact: _________________________________________ Telephone: _______________________

Family Doctor: _________________________________________ Telephone: _______________________

General Information:

Food or drug allergies: ___________________________________________________________________________

Other allergies: ____________________________________________________________________________________

Date of last Tetanus shot: _________________________________________________________________________

Present medications: ______________________________________________________________________________

_______________________________________________________________________________________________________

Chronic medical problems: _______________________________________________________________________

_______________________________________________________________________________________________________

Parental Authorization:

In case of a medical emergency and I cannot be reached, I authorize Sizer, its agents,

employees and other officers to procure consent to any medical examination, diagnostic

process or course of treatment, including hospital care, to be rendered to my child by or

under supervision of any duly licensed doctor, dentist, surgeon, or other health care

professional.

__________________________________________________ __________________________________

Parent/Guardian Signature Date

_________________________________________________ ___________________________________

Health Insurance Company Name Policy Number


One Day Field Trip Permission & Release Agreement

500 Rindge Road, Fitchburg, MA 01420 • School Phone: 978-345-2701 • Fax: 978-345-9127 1

Instructions: Please read the entire form. If there is anything about this form or the described activity that you do not understand, do not sign the form until you are satisfied that you have obtained a complete explanation. Fill in all the blanks. If you have more than one child participating, complete one parent permission form per child.

Please return this completed from to _________________________________by _____________________.

Field Trip Information: Trip to: ________________________________________ Time leaving school: ________________________

Food: ____________________ Travel by: _________________ Time returning to school: _______________

Dates of trip: _____________________ Cost of trip: _________________________

Special notes: (clothing needed, etc.)_______________________________________________________________

Parent Permission & Release Form

I, _____________________________, the parent or guardian of ____________________________, a minor, (parent name) (student name) give permission for my child to participate in the field trip described above. I acknowledge that I have been informed of the activity and the provisions for my child’s involvement, and I consent to my child’s participation in the above described school activity.

In consideration of the permission granted to my child to participate in the above described activity by Sizer School, I release and hold harmless Sizer School, its agents, employees, and officers, from any and all actions or causes of action of any nature for personal injury or property damage of any kind arising in any way from my child’s participation in the above described activity. I understand that a registered nurse will not attend the field trip unless specifically stated. If I have medical/health concerns for our child related to said activity, I will contact the health office to discuss them prior to the day of said activity. I further acknowledge that this release is binding upon my heirs, successors or assigns, that I have read the foregoing and understand its significance, and that I have executed this document voluntarily. In witness whereof, I have signed this document on the _______ day of _______________________, 20_____ ____________________________ ____________________________________________ _________________________

Parent or Guardian Address Telephone Number

I acknowledge that I have been informed of all expectations of me as included in the Sizer Field Trip Policy and agree to abide by these expectations. ______________________________________ _______________________________________

Parent/Guardian Signature Student Signature


mailto:[email protected]

P6005.1 – Student Transportation in Private Vehicles

500 Rindge Road, Fitchburg, MA 01420 • School Phone: 978-345-2701 • Fax: 978-345-9127

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Transportation to and from school-sponsored events can often pose a challenge for families

and the school. How parents/guardians decide to transport students between their homes

and school each day is each parents/guardian's individual decision and responsibility.

NCCES adults including volunteers may, at their discretion, choose to transport students of

NCCES in their private vehicles to or from school or school-sponsored events that fall

within the academic day, extend the school day or occur on weekends or school vacation

periods provided all the following conditions are met. (*):

1. Each vehicle should contain a copy of the permission form for the students being transported in that vehicle. The school should have on file a permission slip for each student that allows them to be transported in a private vehicle.

2. The activity has the approval of the Executive Director of NCCES or his/her designee.

3. Students never drive other students, even if they are 18 years of age or older.

4. The adult driver is a properly licensed driver over the age of 21 with a good driving record and a registered/insured vehicle with an up to date inspection sticker.

5. The adult driver must follow all the established rules of the road, i.e., following the speed limit and modeling appropriate vehicle safety practices including keeping a two-car-length distance between the adult driver’s car and the car ahead of you, not talking or texting on a cell phone or other personal electronic device, not using ear buds or headphones, and driving with headlights on.

6. The adult driver has satisfactorily passed a criminal records background check (CORI).

7. The vehicle that will be used to transport students is properly maintained and inspected by the MA Registry of Motor Vehicles.

8. If traveling in one vehicle, the adult driver agrees to avoid one-on-one situations with individual students by ensuring that another student or employee/staff member/adult is present.

9. If a group is traveling in more than one vehicle, the entire group must consist of at least two unrelated, approved adult volunteers. Care should be taken so that a single car (with a single adult driver) is not separated from the group for an extended length of time.

* Private transportation includes private passenger vehicles, rental cars, privately

owned or rented recreational vehicles and campers, chartered buses, and chartered

flights. Each driver of a motorized private transportation must be at least 21 years

old and hold a valid operator’s license appropriate to the vehicle –state laws must

be followed, if they are more stringent than the guidelines here.

P6005.1 – Student Transportation in Private Vehicles

500 Rindge Road, Fitchburg, MA 01420 • School Phone: 978-345-2701 • Fax: 978-345-9127

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10. The owner of the vehicle being used in transporting students must file evidence with the Executive Director, or his/her designee, of personal liability insurance coverage on the vehicle in the amounts of $100,000 - $300,000 or more.

Required coverage for MA auto insurance and the required minimum limit for each

coverage:

Bodily Injury to Others $20,000 per person; $40,000 per accident

Personal Injury Protection $ 8,000 per person, per accident

Bodily Injury Caused by an $20,000 per person; $40,000 per accident

Uninsured Auto

Damage to Someone Else’s Property $ 5,000 per accident

11. The student(s) will be placed in the back seat of the vehicle whenever possible. All students 12 years or younger must be in the back seat.

12. Never transport students in flatbed or panel trucks, in the bed of a pickup, or in a camper-trailer. (Exclusion may apply for special circumstances such as participating in a parade when other safety guidelines apply)

13. All adults and student(s) must wear a seatbelt.

14. Any travel or transportation of students in private vehicles for activities that involve late night travel are not recommended or supported by the school.

15. Plan rest stops every few hours; if driving with others, prearrange stopping places along the way. When planning longer trips, arrange for relief drivers so that drivers are not driving for more than 6 hours

16. School personnel and parents/guardians of students to be transported in this manner will be fully informed as to this means of transportation and will sign a statement to this effect.

Board Approved 7/14/14

P6006.1 – Renting or Chartering Private Transportation

500 Rindge Road, Fitchburg, MA 01420 • School Phone: 978-345-2701 • Fax: 978-345-9127 1

Passenger vans can be rented by registered volunteers with safe driving records only with

the approval of Executive Director of NCCES. No vehicle larger than 12 passenger vans will

be considered for approval.

Rental agreements should be in the name of the volunteer and not the school, (enabling

volunteers to sign the rental agreement). Volunteers must take out the extra insurance that

is offered by the rental company.

Written agreements are always required when renting or chartering, even if there is no

cost associated with the rental. If an agreement must be in the name of the school, the

volunteer is not authorized to sign the agreement and must instead contact the school for

review and signing.

Check with school to make sure you are following accepted practices when using private

transportation; this ensures that both you and the council are protected by liability

insurance in the event of an accident.

If the school has given permission to use a rental car, read all rental agreements to be sure

you comply with their terms and avoid surprises. Note the minimum age of drivers (often

25), as well as the maximum age (often under 70). Be sure the car is adequately insured,

knowing who is responsible for damage to or the loss of the vehicle itself. Also, ensure you

have a good paper trail, with evidence that the vehicle rental is school related.

Board Approved 07/14/2014

Fitchburg/Leominster

203 Airport Rd. PHONE: 978-342-7255

Fitchburg, MA 01420 FAX: 978-342-9777

1

CUSTOMER

REQUESTING CHARTER ____ CHARTER SCHOOL ___________ PHONE#___________________________

BILLING ADDRESS ________________________________________ FAX# _____________________________

CITY ________________________ ST ___________ ZIP CODE ____________DATE ORDERED ___________ Round One

Trip Date: ____________________ DAY OF WEEK (circle) __S M T W T F S__ Trip Way

Trip Times:

Load AM Depart AM Time for AM Time of Arrival AM Time: PM Time: PM Return P/U: PM @ Home: PM

TRIP INFORMATION:

NEW ORDER CHANGE ORDER PASSENGER COUNT

BUS SIZE 3 Per Seat 2 Per Seat # of BUSES CHILDREN

77 Passenger 77 Kids 51 Adults ADULTS

71 Passenger 71 Kids 47 Adults

TOTAL

GROUP NAME/

ACTIVITY ______________________________________________________________________________________________________________________________________

PICK-UP INFORMATION:

P/U Location: Address: City: Zip: Special Instructions: Bus to Stay: Yes No

DESTINATION INFORMATION:

Destination: Address: City: Zip: Special Instructions:

ORDERED BY:

First Student Office Use Only

Confirmation #: Calc. code: #Buses: Estimated Cost: Date Faxed: # Passengers: Customer #: Price Code: COD INV P.O.#:

School Principal ________________________________________________________________________________

Documents

SIZER FIELD TRIP REQUEST & PLANNING FORMS FIELD TRIP REQUEST & PLANNING FORMS 500 Rindge Road, Fitchburg, MA 01420 • School Phone: 978-345-2701 • Fax: 978-345-9127 Page 3 of 4