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Puyallup School District Form 2320F1
Field Trips, Excursions and Outdoor Education Instruction

Step 1 - Request for Field Trip

School Destination
Applicant Departure Date Time
Date of Application Return Date Time
Purpose of Trip (application to the curriculum):

Itinerary:

Person in Charge: Type of Event (parade, contest, etc.) ___________
Number of Teacher Chaperones: __________ Groups participating (orchestra, debate team, etc)
Number of Parent Chaperones: __________ _______________________________
Number of Participating Students: _________
TRANSPORTATION: Cost $___________________
(Type: School bus, chartered bus, ferry, etc)
If bus is to be used, the following must also be completed:
Call transportation for estimate if District buses are used.
ESTIMATED COST: ________________ Recorded by _____________________
(Transportation personnel)
Cost figured on basis of ________ buses. Date: __________________________
HOUSING: ____________________________________________ Cost $__________________
(Type: Motel, hotel, dorm, private home, etc.)
FOOD: ________________________________________________ Cost $ __________________
(Group Meals – Number of meals)
OTHER COSTS: ________________________________________ Costs $ _________________
(Sightseeing, entrance fees, extra insurance coverage, etc.)
TOTAL COSTS OF TRIP………………………………………………………$_______________

Source of Funds:
Building Budget: Account code ______________________________costs $_________________
Student Body: Account code ______________________________ costs $_________________
Individual Students: ______________________________ costs $_________________
Other funding source: _______________________________________costs $_________________

Approved by ASB Treasurer (if student body funds are used):_____________ Date: ______________________
Approved by Principal: _________________________________ _ Date: ______________________
Approved by Director of Athletics: __________________________Date: ______________________
Approved by Chief Academic Officer: Date:______________________
Approved by the Superintendent:___________________________ Date: ______________________
If in state, submit this form to building administrator for signature and route to Chief Academic Officer for approval 30 school days (6 weeks) prior to the field trip
activity.
If in state overnight, submit this form to building administrator for signature and route to Dir. of Athletics, Chief Academic Officer for approval and
Superintendent approval 30 school days (6 weeks) prior to the field trip activity.
If out of State (ALL States), submit this form to building administrator for signature and route to Dir. of Athletics, Chief Academic Officer for approval and
Superintendent approval 60 school days (12 weeks) prior to the field trip activity.
International Travel, submit this form to building administrator for a signature and route to Chief Academic Officer for approval and Superintendent for approval
60 school days (12 weeks) prior to the Board meeting.


Puyallup School District
Consent form for Curriculum Related Activities

School: _______________________________ Teacher:

Student’s Name: (first & last)

Will be participating in the following activity:

This involves:

On: Itinerary attached ________________________________
(date of activity) Teacher’s Signature

This activity provides a learning experience for the students and allows them an opportunity to apply their
classroom learning.

TYPE OF TRANSPORTATION: District Vehicle Commercial Transportation
* Private vehicle – driver’s name:

• If a private vehicle is used, the individual driver is responsible for carrying valid liability insurance and maintaining the vehicle in safe
working condition. The District does not encourage use of private vehicles to transport elementary students.

In the event of an accident or illness, I understand that every reasonable effort will be made to contact me
immediately. However, if I am not available, I authorize the Puyallup School District to secure emergency
medical care as needed.

Although I understand that the Puyallup School District will make every reasonable effort to provide a safe
environment, I am fully aware of the special dangers and risks inherent in participating in the activity, including
physical injury, or other consequences arising or resulting from the activity.

Being fully informed as to these risks, I hereby consent to the student participating in the activity.

Parent/Guardian Name: Student:

Home Address:

Telephone:

(signature of parent/guardian) (date)

Field Trips, Excursions, and Outdoor Education Instruction

Consent Form for Noncurriculum Activities

School: _______________________________ Teacher:

Student’s Name: (first & last)

Will be participating in the following activity:

This involves:
On: Itinerary attached ________________________________
(date of activity) Teacher’s Signature

This activity provides a learning experience for the students and allows them an opportunity to apply their
classroom learning.

TYPE OF TRANSPORTATION: District Vehicle Commercial Transportation
* Private vehicle – driver’s name:
• If a private vehicle is used, the individual driver is responsible for carrying valid liability insurance and maintaining the vehicle in safe
working condition. The District does not encourage use of private vehicles to transport elementary students.


Student’s name has my permission and authorization to participate in the above-
named activity.

I am fully aware of the special dangers and risks inherent in the activity, including physical injury or other
consequences that may arise or result directly or indirectly from the activity. Being fully informed as to the
risks and in consideration of the privilege of participating in the above described activity, I hereby assume all
risk of injury or liability and waive any right of recovery from or to bring suit against the Puyallup School
District, its officers, agents, and employees for any personal injury or other consequences arising out of
participation in the activity, except for the sole negligence of the school district.

I certify that I am the parent or legal guardian of the participant named above; that I have read and understood
the foregoing release: and that I join in the release without reservation, granting full consent and authorization
for the above person to participate in the activity.

(signature of parent/guardian) (date)

Parent/Guardian Name: Student:
Home Address:
Telephone:


Student Personal Medical Insurance Coverage
Field Trip or Tour Use Only

Student Name:

Address: City: Zip:

Birthdate: Grade: Sex: Home Telephone:

Parent/Guardian Name: Work Telephone:

Name of person to call in case of an emergency when the parent/guardian is not available:

Emergency Contact: Telephone:

Family Doctor: Telephone:

Medical restrictions of student:

The Puyallup School District does not carry insurance to cover medical treatment of students. Parents should
consider obtaining student accident insurance as a supplement to any other health insurance they may maintain.

Accident Medical Insurance Information:
The above named student is covered by the following personal medical/dental:

Medical Insurance: Policy No:
Dental Insurance: Policy No:
Student Insurance: Policy No:


Signature of Parent/Guardian Date:

District use: Keep this form in the student’s cumulative file for one school year.


Volunteer Request for Authorization to Transport Students

Any volunteer, who transports students for school activities in a private vehicle, must complete
and submit this form to the building administrator for approval. Volunteers are not authorized to
transport students until they receive notification from the building administrator that their
request form has been approved. Approval to transport students is only valid for the date(s)
indicated. If deemed necessary, the Puyallup School District reserves the right to request a
volunteer’s Abstract of Driving Record from the Department of Licensing.

Name of driver (Last, First, Middle)_____________________________________________

Drivers’ License #:____________________State:____ Expiration Date: ___________

Auto Liability Insurance Carrier: Agent: _________________

Phone No: Policy No:_______________ Exp. Date: ___________

Circle Yes or No:
• Yes No I am at least 21 years of age.

• Yes No I have a valid Washington State driver's license.

• Yes No I have an active auto liability insurance policy (policy information provided above) that
carries the State minimum, or greater, limits of coverage. The policy includes coverage for general
liability, bodily injury, property damage, and uninsured/underinsured motorist (for use when driving
students in your personal vehicle).

• Yes No I understand that If I am involved in a motor vehicle accident while driving my personal
vehicle on school related business, that my personal auto insurance policy will be considered the
primary insurance coverage, and that any and all claims will be submitted to my personal insurance
carrier for payment. The Puyallup School District’s liability insurance coverage will be considered
secondary coverage, and applicable only after all limits under my personal insurance policy have been
exhausted.

• Yes No I certify that my vehicle has no known mechanical defects, and no known safety
deficiencies.

• Yes No I certify that all occupants of any vehicle I use to transport students will be required to
individually wear a seat belt, including both the driver and passengers. If the vehicle I am driving to
transport students is equipped with a passenger side air bag, I will not allow any student to ride in the
front passenger seat if they are less than 12 years old, or weigh less than 100 pounds.

• Yes No I understand that I may only transport students in vehicles with a rated capacity 0f 10
passengers, including the driver, or less. Any vehicles with a greater than 10 passenger rated capacity
are prohibited.

• Yes No I agree to report to the school principal (or designee) regarding any and all accidents,
regardless of how minor, that I am involved in while transporting district staff, volunteers, or students.

• Yes No I certify that I have no known medical condition that would adversely affect by ability to
safely transport students in a motorized vehicle.

• Yes No I have had a moving [vehicle] violation(s) within the last three (3) years. (If “Yes,” list
violation and date):

Violation: Date:

Please note that no person shall be authorized to transport students for the Puyallup School District, if in the
preceding three(3) year period, has been convicted or cited by lawful authority for the following:

1. DUI/DWI 9. More Than Two Citations in a 3-year period
2. Deferred Prosecution 10. Suspended License – Moving and Administrative Action
3. Negligent Driving 11. Failure to Appear
4. Reckless Driving 12. Vehicular Homicide
5. Open Container Violation 13. Vehicular Assault
6. Speeding (11 MPH or more excess) 14. Road Rage
7. Violating License Restrictions 15. Hit and Run Driving
8. Illegal Drugs 16. Other Citations (as deemed appropriate)

I certify that I have answered all of the above questions truthfully and have not withheld any information.

Signature Date

* Before submitting this form for approval, please attach a photocopy of your current driver’s license
and proof of insurance.
________________________________________________ ______________ ____

For Approving Authority Use Only:
_____ Washington State Patrol background check conducted.

_____ All students have parental permission to ride with a volunteer driver.

The above individual’s application is: APPROVED DENIED

Dates this volunteer is approved to drive students: __________________to _______________

_____
Signature Title Date

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