File:  JJH-E-1 - REQUEST FOR APPROVAL OF DISTRICT STUDENT TRAVEL

SCHOOL: ___________________________________ SPONSOR: ______________________

DESTINATION: ___________________________________ DATES: ____________________

I.  EDUCATIONAL ASPECTS:

Does the proposed trip support student performance of District academic standards?  [ ] Yes   [ ] No

Does the proposed trip meet District expectations of co-curricular programs?  [ ] Yes  [ ] No

If yes, enclose explanation of educational objectives.

Does the proposed trip meet CHSAA guidelines?  [ ] Yes  [ ] No

II.  SPECIFIC DATA:

No. of Student Participants:  District _______________________ Non-District _________________

No. of Teacher/Sponsor Participants:  District ________________ Non-District_________________

No. of Chaperones (non-employee adults):  District ____________ Non-District ________________

ATTACH A LIST OF NAMES OF NON-DISTRICT PARTICIPANTS

Number of Chaperones/Sponsors, expenses to be included with students: ____________________

Number of Chaperones Sponsors, expenses to be paid individually: _________________________

How many days will students be out of school? __________________________________________

Number of substitute teacher days required for this trip: ___________________________________

If other schools are involved, please identify: ____________________________________________

Have provisions been made to cope with emergency/disciplinary situations?

Explain: _________________________________________________________________________

________________________________________________________________________________

The estimated cost of the trip per student is $ ___________________________________________

ATTACH COPY OF ITINERARY, TRIP COSTS, AMENITIES (e.g. TOURS, EXCURSIONS, TRANSPORTATION, ACCOMMODATIONS, MEALS), ACTIVITIES AND INSURANCE.

Is fund-raising a necessary part of the program?  [ ] Yes  [ ] No

III.   ATTESTATION OF SPONSOR:

I will not accept any honorarium, fee, or payment for my participation or for any students' participation in this travel program.  I am familiar with the District's conflict of interest policy (GBEA and GBEA-E).

__________________________________________   _______________________

      (Sponsor's signature)                                                              (Date)

IV.   PRINCIPAL APPROVAL:

__________________________________________   _______________________

       (Principal's signature)                                                            (Date)

V.    SUPERINTENDENT APPROVAL:

__________________________________________   _______________________

       (Superintendent's signature)                                                 (Date)