Sacramento START Field Trip 8-Week Checklist

1. Sacramento START • Field Trip 8-Week Checklist PG. 1 OF 3

2. Sacramento START • Field Trip 8-Week Checklist PG. 2 OF 3

3. Sacramento START • Field Trip 8-Week Checklist PG. 3 OF 3

4. Sacramento START • Preliminary Field Trip Proposal (1 of 2) STEP 1 • Use the Field Trip Directory to assist with finding a destination • Preliminary Field Trip Proposal &Field Trip ItineraryMUST be submitted two months prior to the event date • All Field Trips must celebrate the Mission & Vision of Sacramento START • Late and/or incomplete Field Trip Proposals & Preliminary Field Trip Itinerary will not receive approval • All START field trips must be pre-approved by the Site Ops Team and principal prior to any arrangements and announcements to START participants • SITE CONTACT INFORMATION • Today’s date: ____/____/____ Site: ___________________________________________________________________ • Site Director: _________________________________ Site Phone: ( ) ____-______ Email: __________________ • FIELD TRIP INFORMATION • Field Trip Destination: ________________________________________________________________________________ • Address: ____________________________________________ City:_________________ C.A. Zip: _________________ • Date of Trip: ____/____/_____ Departure Time: ____:____ p.m. Return Time: ____:____ p.m. • Educational Benefit of the Trip: _______________________________________________________________________ • ______________________________________________________________________________________________________ • INFORMATIONAL CONTACT • Have you made an initial phone call to the field trip destination? Yes No • Contact Person’s Name: __________________________Phone Number: ( ) ____-______ Email:_____________ • ADMISSION • Estimated # of Students Attending: ____ Grade Level ____ Adults Attending: ____ • Cost per Child $____ Cost per Adult $____ Discounts/Group Rate: Yes No Discount $____ • Total Proposed Cost Of Field Trip Admission: $_______________ • SUPPER/SNACK • Can students consume food on field trip grounds? Yes No • If no, where will students consume supper/snack? On Campus Off Campus • STUDENT “WHAT TO BRING” LIST: • ______________________________________________________________________________________________________ • ______________________________________________________________________________________________________ • STUDENT “WHAT NOT TO BRING” LIST: • ______________________________________________________________________________________________________ • ______________________________________________________________________________________________________ •  TRAVEL • Means of Travel: Bus Walking Public Transportation Other:____________________________ • Field Trip Distance: ____Miles Length of Drive: ____Hours ____Minutes START 2013-14

5. Sacramento START • Preliminary Field Trip Proposal (2 of 2) STEP 1 • ON-SITE (STAFF NOT PARTICIPATING ON FIELD TRIP) • Staff Names (Non-Participants): ______________________________________________________________________ • Substitute Needed: Yes No •  FUNDING • How do you plan to fund this field trip?_______________________________________________________________ • ______________________________________________________________________________________________________ • District support provided: Yes No Explain: ____________________________________________________ •  VISION & MISSION • Describe how this field trip fits into the Vision & Mission of the Sacramento START Program: ______________________________________________________________________________________________________ • ______________________________________________________________________________________________________ • Materials/Resources Needed: ________________________________________________________________________ • APPROVAL • Reviewed PRELIMINARY FIELD TRIP PROPOSAL with Principal on: ____/____/____ • Principal’s request: __________________________________________________________________________________ • ______________________________________________________________________________________________________ • Principal’s Signature: _________________________________________________ Date Approved: ____/____/____ •  TIME CONFLICT • Is there a conflict with School’s Release Time: Yes No • Early release approval needed at: ____:____ p.m. • Approval from Principal: Yes No (Principal’s Initials:______) Related Brochures/Information Attached?  Yes  No Does The Trip Involve Any Of The Following: In/Around Water  Outdoors  Animals OFFICE USE ONLY _____ APPROVED Proceed by submitting a FIELD TRIP ITINERARY _____ DENIED See comments below regarding Policy & Procedure _____ REQUEST IN PROGRESS Schedule an appointment for more information Comments:_________________________________________________________________________________________________________________________________________________________________________________________________ Program Supervisor: ____________________________________________________________ Date: ____/____/____ Total Proposed Cost of Field Trip Admission: $_______________ Total Proposed Cost of Field Trip Travel: $_______________ Total Proposed of Field Trip (Admission & Travel): $_______________ Superintendent’s Signature: ____________________________Date: ____/____/____ APPROVED DENIED Budget approved by superintendent: Yes No START 2013-14

6. Sacramento START • Field Trip Itinerary (1 of 2) STEP 3 • SITE CONTACT INFORMATION • Today’s date: ____/____/____ Site: _________________________________________________________ • Site Director: ________________________ Site Phone: ( ) ____-______ Email: __________________ • FIELD TRIP INFORMATION • Field Trip Destination: ______________________________________________________________________ • Address: ____________________________________ City:_________________, C.A. Zip: _______________ • Date of Trip: ____/____/_____ Departure Time: ____:____ p.m. Return Time: ____:____ p.m. •  TIME CONFLICT • Is there a conflict with School’s Release Time: Yes No • Early release approval needed at: ____:____ p.m. • TRANSPORTATION: • Means of Travel: Bus Walking Public Transportation Other:____________________________ • # of Adults Riding the Bus: ____ # of Students Riding the Bus: ____ • Total # of Participants Riding the Bus: ______ • Total Proposed Cost Of Field Trip Admission: $____ •  STUDENT TO STAFF RATIO • Standard; 1 to 10 aquatics; 1 to 8  Number of Staff/Volunteers needed:_____ • Field Trip Staff Names: ______________________________________________________________________ • Processed and Cleared Volunteers Names: ___________________________________________________ • Copy of Volunteer Clearance Attached: Yes No • SUPPER/SNACK • Can students consume food on field trip grounds? Yes No • Where will students consume supper/snack? _______________________________________________ • Food Services Contacted? Yes No • Person Contacted from Food Services: _______________________________________________________ • Perishable Items:  Yes  No Location of Storage for Food on Trip :__________________________ • Trash Bags Needed:  Yes  No Staples: Can Liners-Item #: 518102: $13.39 (50/bx.) • ON-SITE (STAFF NOT PARTICIPATING ON FIELD TRIP) • Staff Names (Non-Participants): _____________________________________________________________ • Person In-Charge:___________________________________________________________________________ • Substitute Needed: Yes No Attached a Sub Request Form: Yes No START 2013-14

7. Sacramento START • Field Trip Itinerary (2 of 2) STEP 3 •  HAZARD ASSESSMENT: • Potential Hazards: • _____________________________________________________________________________________________ • _____________________________________________________________________________________________ • _____________________________________________________________________________________________ • SUPPLIES AND EQUIPMENT FOR STAFF TO BRING: • Cell Phone • First Aid Kit • Completed Permission Slips • Updated Student Rosters • Site Operations Communication Protocol • 24-hour Contact List • ___________________________________________ • ___________________________________________ • ___________________________________________ • ___________________________________________ • ___________________________________________ • 24-HOUR CONTACT LIST: • Principal’s 24-Hour Emergency Contact #: __________________________________________ • District’s Area Specialist Contact #: _________________________________________________ • Area Specialist Name: _______________________________________________________ •  ITINERARY START 2013-14

8. STEP 3 Sacramento STARTSUB REQUEST FORM Today’s Date: ____/____/_____ Site Director: ________________________________ Site: _____________________________________ Site Phone: ( ) ____-______ Email: __________________ FIELD TRIP INFORMATION Field Trip Destination: ______________________________________________________________ Address: ____________________________________ City:_________________ C.A. Zip: _________ Date of Trip: ____/____/_____ Departure Time: ____:____ p.m. Return Time: ____:____ p.m. SUB REQUEST INFORMATION Number of Substitutes requesting: _____ Grade Level Needed: Primary  Intermediate  Substitute Field Trip Orientation (2-Weeks before trip): ____/____/_____ Time: ____:____ p.m. to ____:____ p.m. Request Steps: Request – complete the Sub Request form & submit for approval 6-weeks before field trip Site Director Request– complete request section for field trip & submit with payroll Program Supervisor Authorization – complete approval for Sub Request & Submit to Sub Coordinator within 1 week; provide Site Director with copy Sub Coordinator Authorization – complete approval for Sub Request & email site staff of approval or denial within 2 weeks Be Advised: All Requests must be submitted 6- weeks in advanceto assign a substitute; Field Trips not within ratio will jeopardize your fieldtrip! AUTHORIZATION SITE DIRECTOR: X__________________________________________________________ Date: ____/____/_____ COMMENTS: __________________________________________________________________________________ PROGRAM SUPERVISOR: X ____________________________________________________Date: ____/____/_____ APPROVAL: _____Yes _____ No Date: ____/____/_____ COMMENTS: __________________________________________________________________________________ SUB COORDINATOR: X ______________________________________________________Date: ____/____/_____ SUB ASSIGNED: _____Yes _____ No Date Assigned: ____/____/_____ COMMENTS: __________________________________________________________________________________ 2013-14

9. Sacramento STARTOn-Site Program Plan for Non-fieldtrip Participants STEP 5 It is essential to provide quality programming for students that are not participating in the fieldtrip. The chart below should serve as a lesson plan that breaks the program time into transitions: academics, rotation 1 and rotation 2. Site Directors need to describe the activities taking place on the field trip day and debrief with the staff in charge, so they are fully aware of their responsibilities. START 2012-13

10. Sacramento START • Field Trip Permission Slip • Page 1 of 2 STEP 3&5 • Please return this permission slip to START Staff by: ____/____/____ • Our START program will be going on a Special Field Trip soon. We will be leaving the site and traveling on this trip during program time. After you read the information below, regarding the field trip, we ask you to sign and date the consent form for you child to join us on this rewarding event. If you have any questions or concerns, contact the Sacramento START staff. • FIELD TRIP PLAN • Site Name: __________________________________________________________________ • Field Trip Location: __________________________________________________________________ • Field Trip Date/Day: __________________________________________________________________ • Field Trip Site Departure: ___________________________Field Trip Site Arrival: _____________________ • Purpose of Fieldtrip: __________________________________________________________________ • Site Director’s Name : __________________________________ Phone #:________________________ • Transportation for this activity will be provided by: Bus Walking Distance: _________ miles • Students will have snack/supper  On Campus  Off Campus • Food will be provided at (time): _________ by: ______________________________________________________ • Students will need to bring money Yes No Purpose for Money:______________________________________ • PARENT/GUARDIAN NEEDS TO COMPLETE THE INFORMATION BELOW • I hereby give my permission for (Name of Student)__________________________to attend the field trip on the scheduled date and time listed above. • I received a detailed itinerary of the trip Yes No • I received a list of things the student should/should not bring Yes No • MEDICAL/ EMERGECNY INFORMATION • Student's Home Phone # _________________________Date of Birth ____/____/____ Grade: ____ • Student’s Address: _________________________________________________________ • Does the student have any medical or physical condition, medication information, or allergies which could interfere with the student’s safety? Yes No • If yes, please describe: _____________________________________________________________________________________________________________ • ________________________________________________________________________________________________________________________________________ • PARENT/GUARDIAN EMERGENCY CONTACT INFORMATION: • Parent/Guardian Name: ________________________________________________ • Work Phone #: ____________________________________________________ • Home Phone #: ____________________________________________________ • Cell Phone #: ____________________________________________________ START 2013-14

11. Sacramento START • Field Trip Permission Slip • Page 2 of 2 • INFORMED CONSENT • As the parent/guardian of the above named student, I have read the field trip itinerary and I understand that there are risks of physical injury associated with participation in these activities. • I authorized qualified emergency medical professionals to examine and in the event of injury or serious illness, administer emergency care to the above name student. I understand every effort will be made to contact me to explain the nature of the problem prior to any involved treatment. In the event it becomes necessary for the staff-in-charge to obtain emergency care for my student, neither he/she nor the Sacramento START Program assumes financial liability for expenses incurred because of the accident, injury, illness and/or unforeseen circumstances. • I understand these activities are an extension of the school education program and student conduct is to be in accordance with the school’s published rules and regulations. • I assume full responsibility for the above participant’s behavior and agree to pay for all damages to property and/or persons caused by the participant mentioned above. • I agree to release and discharge in advance the City of Sacramento their officers, employees and agents, from any and all liability for personal injury, death or property damage connected with my participation even though that liability may arise out of their negligence or carelessness.  • Signature of parent/guardian: _____________________________________ Date: ____/____/____ • Printed name of parent/guardian: ____________________________________________________ • Special Instructions for my child:_____________________________________________________ • _______________________________________________________________________________ • _______________________________________________________________________________ In the event of an emergency (injury, illness, unforeseen incident), I wish the following person to be notified in case I cannot be contacted: Name: _______________________________ Relationship: _______________________ Phone #: _______________________________ Alternate Phone #:____________________ • STUDENT PLEDGE • I pledge that my conduct will, at all times, reflect credit upon myself, my parents, and my school. I understand that the school rules of conduct apply while on the trip. • Signature of Student:: _________________________________________ Date: ____/____/____ START 2013-14

12. Sacramento START • Field Trip Reminder Notice STEP 3&7 FIELD TRIP PLAN We would like to remind you about our field trip by providing this reminder notice that contains all the trip details. If you haven’t done so, please complete the field trip permission form provided by the site director and return it as soon as possible before the deadline date. Site Name: __________________________________________________________________ Field Trip Location: __________________________________________________________________ Field Trip Date/Day: __________________________________________________________________ Field Trip Site Departure: ___________________________Field Trip Site Arrival: _____________________ Purpose of Fieldtrip: __________________________________________________________________ Staff Contact Name : _________________________________ Phone #:_________________________ Transportation for this activity will be provided by: Bus Walking Public TransportationOther:____________ Field Trip Distance: _________ miles Students will have snack/supper  On Campus  Off Campus Food will be provided at (time): _________ by: ______________________________________________________ Students will need to bring money Yes No Purpose for Money:_____________________________________ LIST OF ITEMS TO BRING/ NOT TO BRING: ITINERARY START 2013-14

13. Sacramento START • 24-Hour Contact List Step 6 In case of an emergency, it is important to provide a complete 24-hour Contact List to participating staff and non-participating staff. In an Emergency…DIAL 911 Police (Non-Emergency): __________________________________________________________________ Fire (Non-Emergency): ____________________________________________________________________ • 24-HOUR CONTACT LIST • Ken McCulloch: 916.825.7166 (Cell) 916.808.5264 (Desk) • Joanne Marson: 916.826.9256 (Cell) 916.808.6089 (Desk) • Brian Fitzgerald: 916.835.7991 (Cell) 916.808.6197 (Desk) • START Office: 916.808.6197 (Luz/Front Desk) • Principal’s 24-Hour Emergency Contact #: _________________________________________ • District’s Area Specialist Contact #: ________________________________________________ • Area Specialist Name: _______________________________________________________ • Site Ops Supporting Coach #: ______________________________________________________ • Coach’s Name: ______________________________________________________________ • Sacramento START • SUPPLIES AND EQUIPMENT FOR STAFF TO BRING • SUPPLIES AND EQUIPMENT FOR STAFF TO BRING: • Cell Phone • First Aid Kit • Completed Permission Slips • Updated Student Rosters • Site Operations Communication Protocol • 24-hour Contact List • ___________________________________________ • ___________________________________________ • ___________________________________________ • ___________________________________________ • ___________________________________________

14. I.C.E. CARDS INSTRUCTIONS: An ICE Card is a card each participant carries all day on the fieldtrip. If a student is in an emergency situation and needs to communicate with the field trip personnel or police, the ICE Card holds all the important information required by first responders to ensure our students needs are properly and safely met. Please complete the areas in grey font. Once the information is completed, change the font to black. On the day of the fieldtrip, provide an ICE CARD to all students attending the fieldtrip. Sacramento START Program Field Trip In Case of an Emergency Card (I.C.E. CARD) My START Program: (Insert School Name Here) My Site Phone Number: (Insert Phone Number Here) My Site Director/Leader Name: (Insert SD/Leader’s Name Here) This I.C.E Card must be carried by student at all times. I.C.E. Card (BACK SIDE) (1) IN CASE OF AN EMERGENCY: Contact (SD Name Here & Site #) (2) IN CASE OF AN EMERGENCY : Locate a uniformed START Staff Member or Police Officer (3) IN CASE OF AN EMERGENCY: Notify Ken McCulloch (916) 825-7166 Sacramento START – (916) 808-6197 5735 47th Avenue – Sacramento, CA 95824 I.C.E. Card (BACK SIDE) (1) IN CASE OF AN EMERGENCY: Contact (SD Name Here & Site #) (2) IN CASE OF AN EMERGENCY : Locate a uniformed START Staff Member or Police Officer (3) IN CASE OF AN EMERGENCY: Notify Ken McCulloch (916) 825-7166 Sacramento START – (916) 808-6197 5735 47th Avenue – Sacramento, CA 95824 Sacramento START Program Field Trip In Case of an Emergency Card (I.C.E. CARD) My START Program: (Insert School Name Here) My Site Phone Number: (Insert Phone Number Here) My Site Director/Leader Name: (Insert SD/Leader’s Name Here) This I.C.E Card must be carried by student at all times. I.C.E. Card (BACK SIDE) (1) IN CASE OF AN EMERGENCY: Contact (SD Name Here & Site #) (2) IN CASE OF AN EMERGENCY : Locate a uniformed START Staff Member or Police Officer (3) IN CASE OF AN EMERGENCY: Notify Ken McCulloch (916) 825-7166 Sacramento START – (916) 808-6197 5735 47th Avenue – Sacramento, CA 95824 Sacramento START Program Field Trip In Case of an Emergency Card (I.C.E. CARD) My START Program: (Insert School Name Here) My Site Phone Number: (Insert Phone Number Here) My Site Director/Leader Name: (Insert SD/Leader’s Name Here) This I.C.E Card must be carried by student at all times. START 2013-14

15. Sacramento START • Field Trip Master Student Roster Form STEP 6 Date of Trip: ____/____/_____ Departure Time: ____:____ p.m. Return Time: ____:____ p.m. Educational Objective: ______________________________________________________________________ Location: ___________________________________________________________________________________ Program: _____________________________________ Cluster: ____________________________________ START 2013-14 Approved by Site Director: ____________________________________ Date: _______________________

16. Sacramento START • Field Trip Student Tracking Roster STEP 6 Date of Trip: ____/____/_____ Departure Time: ____:____ p.m. Return Time: ____:____ p.m. Educational Objective: __________________________________________________________________________ Location: ____________________________________________________________________________________ Staff Member’s Name : ___________________________________ Grade : ______ Number of Students: ______ START 2013-14

17. Sacramento START • Staff Field Trip Emergency Card STEP 7 START 2013-14

18. Sacramento START • Field Trip Reflection for Students START 2013-14