File:  IICA-F



Current Date:  _____________________________      School:        ahs            cms            ces            mves            ses


Field Trip Name:  ___________________________       ~Activity/Class/Group:  ______________________________ 


Teacher(s)/Sponsor(s):  ____________________________________________________________________________


Teacher(s)/Sponsor(s) Email:


Number of:  Students:  __________              Adults/Chaperones:  __________


NUMBER of students with emergency plans or scheduled medications:  __________

  **Notification of field trip must be submitted to the school nurse two weeks prior to the trip


 ~Name(s) of Adults/Chaperones Attending:  ________________________________________________________




~Educational objectives:  (list by narrative and SOL, if applicable)  _________________________________________






~Funding source:  _________________________________________________________________________________




departure:         ahs            cms            ces            mves            ses


Departure Date:           _______________          Departure Time:           ____________


Return Date:                  _______________           Return Time:                   ____________



Destination:  __________________________________________________________________________


           Street:  _________________________________________________________________________             


  City:  _____________________________________     State:  _______     Zip:  ________________         


Equipment:          charter Bus           School Bus-REG           School Bus w/ Lift           Van


*Number of Vehicles:  _________

(*K-5 = 45 students max.; 6-12 = 40 students max.; transit buses permit 6-10 additional students.  Van = 7 people max.)


~When completing the online Field Trip Request form, enter this information in the “notes” section under Departure.


NOTE:  This form must be submitted to the Director of Instruction at least two weeks before the date of proposed in-state trips.  It must be submitted at least eight weeks before the date of proposed out-of-state and/or overnight trips.