Florence Unified School District #1 s8

FLORENCE UNIFIED SCHOOL DISTRICT #1 ACTIVITY TRIP REQUEST FORM Date Submitted:9/28/2015 Section 1: Your Contact Information Submitted by: Dominick Capersino Your School Site: Anthem K-8 Your position : Teacher School Phone Number : 520-723-6400 Extension: Your Emergency Contact Number: - - 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: March 4, 2016 through March 6, 2016 Destination of trip: San Diego, CA Date of departure: March 4, 2016 Time of departure: 12:00 midnight Date of return: March 6, 2016 Time of return: 10:00p.m. Purpose of trip: Science / Oceanography Briefly describe trip activities: On-board floating laboratory activity, Sea World with Project Exploration's education booklet, and Stephen Birch Aquarium and Museum.

Name/Address of Site: Name: Project Exploration In, Address: 1701 East Elwood St. City/State Phoenix, AZ Zip Code: 85040 Contact Person at Site (Non-School Personnel): Jenny Stephan Phone Number of Contact Person: 602-448-4800 Means of transportation selected: Private Charter District Provided Buses Parent Provided In general, describe the route to the destination:Interstate 8 to San Diego Number of Students Participating: 50 Number of Chaperones: 3 Estimated total cost of activity trip: Estimated cost per student participant: $300-400 depending on the number of students participating

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? Permission Slips will be collected prior to the departure date 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: Kathy Brown

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. Dominick Capersino Position: Teacher Phone Number: 520-723 -6400

2. 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