CULPEPER COUNTY HIGH SCHOOL

Justification for Field Trip Request

TRIP INFORMATION

 

Activity/Event:                                                                                                                                                                                                              Grade Level and/or Club/Organization:

                                                

                                       

Destination:  (Complete Address)                                                                                                                                                                              Phone Number:

 

                                                   

 

Circumstance that make this field trip unusual:

 Involves student safety or CCHS liability                                               Involves foreign travel

 Involves a water-related activity                                                          Involves overnight trip

    (e.g. amusement park, motel swimming pool)

 

 Emergency Contact:  Name and phone number of person to contact for emergencies.

 

Place of Departure:                                                                                 Time:                                       Date:

                                                                                    

 

Place of Return:                                                                                       Time:                                        Date:

                                                                                     

 

Purpose of trip:

 

 

Is this a repeated trip?      Yes      No                                                      Will this trip be requested 2nd Sem.?      Yes                 No

 

SOLs/Curriculum Focus:

 

 

What lesson objectives will be facilitated by the students’ first-hand experience?  STUDENTS WILL:

 

 

 

Briefly describe/outline the lesson plan(s) used in preparation for this event.  STUDENTS PARTICIPATED IN:

 

 

Briefly describe/outline the lesson plan(s) that will be used as your classroom follow-up activity(ies).  STUDENTS WILL:

 

 

Briefly des the planned assessment activity(ies) related to the objectives in this learning activity.  STUDENTS WILL:

 

 

 

Financial Cost(s) per student:

                                                       Transportation     Food    Admission(if applicable)

 

                                                       Other                     TOTAL COST

 

SOURCE OF FUNDS:

Mode of Transportation:    School Bus* (This form of transportation is limited at a 50 mile radius).  Will this require facilities

                                           For special needs?  Yes    No                                                 

                                                Commercial Carrier* (Contracts for this are to be submitted by the bookkeeper only).

                                                 County Vehicle

                                                Other (Includes Metro Bus or Rail, Private Vehicle, Walking, or Leased Vehicle).

                                           

 

Number of buses needed Are special needs facilities needed?      Yes         No

 

*Supervision will be provided by adults directly.  If there are any exceptions, please explain in detail:

 

 

 

Please submit to G. Brown   

 

 

REQUESTER

 

Teacher:                                                 Date:

                            

 

              

 

APPROVED:  YES                NO

 

 

_________________________________________                                     _________________________

Principal or Designee                                                                                    Date

 

Comments:

 

ALL field trips are subject to cancellation and/or rescheduling based on any state or school wide testing, funding, or unforeseeable events.   It is not guaranteed that a reschedule field trip will be approved.  Please check with the administrator for prior approval.