JCS Field Trip Request Form

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The following information must be provided in order for this proposal to be considered

Teacher(s) *

Name of Teacher or Teachers that will be taking students on trip

Email *

Please enter the email address of the person submitting the field trip request form

Date of Field Trip *

Grade(s) or Class(es) *

Grade of students or class which will be going on the field trip.

Number of Students Transported *

Please provide the number of students that will be transported on this trip

Number of Chaperones/Adults transported *

Number of buses requested *

Destination(s) *

Please provide the destination of the field trip. Example: Louisville Zoo

Location: *

Please provide the address of the Destination. Example: 1100 Trevilian Way,

City *

Name of the City of the Destination: Example: Louisville

State *

Departure Time: *

Return Time *

In/Out of County Field Trip? *

Just a reminder that Out-of-County Field Trip rate adds is an additional $28.00,

In/Out of State Field Trip?

Must obtain Board of Education Approval

Out of State

Estimated Round Trip Mileage *

Please provide estimated ROUND Trip Mileage of the trip. PLEASE ONLY PUT IN THE MILES - 80 Miles - Use only 80.

Cost Per 23/24 Procedure Manual - Page 23 *

If Destination is not listed "YOU MUST CHECK WITH BOARD OFFICE" for the correct amount to enter.

Trip Paid by *

How is the trip being paid? Example: School Class Fund, District Gear UP Soar Fund, District Federal Grant

Total Funds Available from Funding Source. *

This is the amount of funds that you have available for trip.

Number of Hours of Trip *

Cost of Bus Driver *

Drive Hrly Rate $11.72; Out-of-County Field Trip Rate $28.00, and Fixed Charges. Using the numbers of hours and the rates presented, calculate the total cost of the driver.

Total Cost of Trip *

To Calculate, Use the Destination Costs Amount + Cost of Driver Pay and if out of county $28.00. Example: Trip to Lexington, KY for 8 hours: Destination cost is $220, Driver Pay is $93.76 and the addition $28.00 for a grand total of $341.76

Volunteer/Unpaid Bus Driver Requested *

Educational Emphasis/Objectives *

What are the objectives of the field trip?

Plan of Action *

Suggested Activities *

Provide a list of activities the students will be doing during the trip.

Evaluation Date

YYYY

Interested in Box Lunches *

Number of Students on Field Trip *

Please provide a number: 15

Number of Box Lunches Requested *

Number of box lunches requested for the field trip.

Teacher’s Signature *

By typing your name, you are digitally signing this form for this field trip.

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