Florence Unified School District #1 s2

FLORENCE UNIFIED SCHOOL DISTRICT #1 ACTIVITY TRIP REQUEST FORM Date Submitted:12/01/2014 Section 1: Your Contact Information Submitted by: Annie Valencia Your School Site: Florence High School Your position : Teacher/Varsity Cheer Coach School Phone Number : 520-866-3560 Extension: 7115 Your Emergency Contact Number: 520-705-6489 Are you designated the trip leader? YES NO If no, who is the designated trip leader? Phone Number for designated trip leader: - -

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: 3/19/15 through 3/23/15 Destination of trip: Anaheim, CA Date of departure: March 22, 2015 Time of departure: 7:00 am Date of return: March 23, 2015 Time of return: 1:00 am Purpose of trip: United Spirit Association Cheerleading Nationals Briefly describe trip activities: The girls will be competing at USA Cheerleading Nationals at the Anaheim Convention Center and going to Disneyland and California Adventure.

Name/Address of Site: Name: Best Western Plus Pavilions Address: 1176 W Katella Ave City/State Anaheim, CA Zip Code: 92802 Contact Person at Site (Non-School Personnel): Laura Phone Number of Contact Person: 714-776-0140 Means of transportation selected: Private Charter District Provided Buses Parent Provided In general, describe the route to the destination:See attached directions Number of Students Participating: 24 Number of Chaperones: 2 Estimated total cost of activity trip: $15000 Estimated cost per student participant: $600

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? All girls have completed medical release forms. Permission slips will be collected by Annie Valencia by March 6, 2015. 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?

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?

Principal has reviewed all documents and approved the Activity Trip recommends sending Agenda Item to the Governing Board? YES NO

Name of Principal: Thad Gates

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. Annie Valencia Position: Varstiy Cheer Coach Phone Number: 520-70 5-6489-

2. Amanda Wilkins Position: Varsity Pom Coach Phone Number: 480-334-5118

3. Tiffany Price Position: Tumbling Coach Phone Number: 480-241 -2631

4. 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