North Sanpete School District
Request for Student Travel requiring approval of the
Superintendent or Board of Education
Note: Educators submitting this request should first read the North Sanpete School District Student Travel Policy. This form must be submitted prior to advertising or reservations for the planned outing.
Indicate Travel Type requested:
☐ A. In-state overnight trips or short notice out of state competiton (most cost less than $500 per student and not miss more than two days of school)
School Board Approval
☐ A. More than 150 miles from Mount Pleasant
☐ B Out of state trips
☐ C. Exceptions to limitations under Superintendent approval
☐ D. Other
School _______________________________________ Group _______________________________________
Teacher(s) Leading Trip ___________________________________________________________________
Dates of Travel ________________________________________ Days of School Missed? _________
How many other overnight trips has the group taken this year? ______________________
This request will not be considered for approval or advancement without complete answers to the questions below:
Educational Justification: What are the educational objectives of this trip that cannot be replicated closer with less travel cost?
Standards for Participants: What are the academic and behavioral standards that must be met by participating students?
Safety: In what way will you insure the safety of students while traveling or participating in activities? (Describe special instructions to students, supervision guidelines to chaperones, etc.)
Lodging: Where will students be staying at night?
Number of Students Traveling? ___________
Number of Adult Chaperones? ____________ (must have same gender chaperones)
Date of Parent Meeting ______________________ (Required for overnight travel)
Method of travel: (check all that apply)
☐ School Vehicle (van, car, etc.)
☐ Parent transporting their own children
☐ Airline (outline ground transportation plan) ________________________________
☐ Other (specify) __________________________________________________________________
Participation by Student is: ☐ Optional ☐ Mandatory
If overnight travel, have parents signed consent forms?
☐ Yes ☐ No ☐ No, but they will prior to departure
Financial: As a school sponsored activity, fee waivers apply. How will you cover the potential costs of fee waivers
How much must a student pay or fundraise to participate? ____________________
Total cost of the trip per students (if other funds are used)? ___________________
I have read the North Sanpete School District Student Transportation Policy, and I understand that I am responsible for the safety / wellbeing of students while on the proposed excursion.
Signature of group leader (must be NSSD employee) Date
I have reviewed the itinerary of the proposed trip and reviewed safety procedures with the supervising educator. I have confirmed that no students will be penalized in any way if he/she cannot participate in this travel experience. I recommend this travel to the superintendent.
Signature of school principal Date
Signature of Superintendent Date
Board Approval Date
Special conditions related to superintendent or Board approval:
North Sanpete School District
Parent Release Form
Student Name ________________________________________________________________________
Parent Name ________________________________________________________________________
Street Address ________________________________________________________________________
City / Zip ________________________________________________________________________
Phone Number Home ________________________________________________
Parent’s Medical Insurance Company _______________________________________________
Insurance Policy Number _______________________________________________
Please list any health issues that the activity advisor should know about, and all medication taken on the trip. (if so, please give instructions)
Name of Activity Dates of Activity
This is to certify that my student has permission to attend the above named activity. In the unlikely event that my student becomes ill or is injured, I authorize the advisor(s) of this activity to act as my agent to secure the services of a physician, dentist or hospital and to incur expenses for necessary services. I will provide for payment costs. (The activity advisor will contact the parent or guardian, as soon as is reasonably possible should medical attention be necessary.) It is understood that students who violate conduct or eligibility rules or who act in a manner that is detrimental to the safety or well being of others may be sent home at the parent’s expense.
I have read and agree to abide by the conditions listed above.
_____________________________________ _________________________________ ________
Student Signature Parent Signature Date