Coach/Sponsor Acknowledgement Form 2012-13 I,, have read and fully understand the Socorro Independent School District s Student Travel Manual.* I understand that it will be my responsibility to adhere to all sections of the guideline. If I do not understand a provision, I shall seek a written clarification. If a student, parent, or any other person requests additional information that I cannot provide, I will refer them to the appropriate administrator. I acknowledge that failure to adhere to any part of the SISD Student Travel Manual shall result in disciplinary action. Signature: Date: Coach/Sponsor/Director *This form is to be completed once a school year. It is to be filed in the appropriate SISD Department. Page 1
Student Travel Acknowledgement Form This form must be completed and signed yearly by both the student and parent/guardian and on file at your school before the student may travel out of town with a Socorro ISD student group. Student s Name:_ Date: Current School: _ I have read and understand the Socorro Independent School District s Student Travel Manual.* I have reviewed the contents of the guidelines with my child. I agree that my son/daughter will abide by all of the rules and expectations of such guidelines. I understand that there will be consequences as per the Student Code of Conduct for failure to adhere to those guidelines. If I have any questions regarding the Student Travel Manual, I am to contact my child s coach/sponsor/director. Signature of Parent/Guardian: Date: Signature of Student: Date: *The SISD Student Travel Manual is located at www.sisd.net Page 2
Coach/Director/Sponsor Trip Checklist Coach/Director/Sponsor Acknowledgement Form Student Travel Manual Acknowledgement Form Completed Overnight Trip Request Completed Trip Request Medical Release Form for all students Parent Permission Form Provided Parents with Itinerary If applicable, completed Alternative Travel Forms Page 3
Trip Itinerary Template Purpose of trip: Dates of trip: Departure time and location: Name of Hotel: Address/ Phone Number of Hotel: Activity times (approximate): Coach/Sponsor contact Information: Page 4
LOCAL FIELD TRIP/VOLUNTARY ACTIVITY PERMISSION FORM ACTIVITY INFORMATION Field Trip/Group Activity: Date of Activity: Destination: Purpose of Activity: Departure Time: Arrival Time: Sponsor In Charge: Number of Chaperones: Cost Per Student: Mode of Transportation: Other Information: Permission is requested for your child to attend the activity. To give permission for your child to attend this field trip, please complete the information and sign below. No student will be permitted to attend this trip who has not completed the form and returned it to the proper school personnel or has altered the form in any way. I understand that there will be no penalty for my child not attending this activity and should it occur during the school day alternate campus supervision and activities will be planned. No penalty of any type will be imposed against the student based upon failure to pay for the activity. No student shall be denied the right to participate for failure to pay for the activity. The principal/district official reserves the right to cancel the activity based on insufficient funds to cover the cost of the activity. Payment is voluntary. Parents/Guardians will be notified of any significant change in plans prior to the activity. I also understand that the trip may include amusement activities and participation in any amusement activities will expose my child to some risk of injury or even death. I have read and understand the description of the field trip (attached) and authorize my child to participate in the planned components of the field trip to the extent indicated by my signature below. I also understand the participation will be off school property. Parent Permission Participation in all aspects of this trip Participation in all aspects of this trip; except the amusement and theme park activities or other as specified. I give permission for: to participate in this activity. Parent Signature: Date: Pupil Agreement While participating in this field trip, I will accept responsibility for maintaining good conduct, appearance, and will follow directions at all times. Pupil Signature: _ Date: Socorro Independent School District cannot be responsible for reimbursement to parents or students of money submitted as advance payment (i.e. shows, musical, concert) for any activity that is canceled. Page 5
Travel Medical Parent Permission Form Student Name: Student ID: Campus: Program/Sport: In the event of a medical emergency while by child is participating on a school trip when the parent/guardian is unavailable, I authorize Socorro Independent School District officials to release the following information to the healthcare provider. I further authorize care and treatment to be performed by any licensed physician or surgeon. I understand school officials will use the contact information provided below to contact me in the event of such emergency. If any emergency medical procedures or treatment are required during the trip, I consent to the trip supervisor(s) arranging for and consenting to the procedure or treatment in the supervisor s discretion. I understand that I will be responsible payment of any such medical procedure or treatment. STUDENT INFORMATION: NAME: _ STUDENT ID: ADDRESS: ZIP: HOME PHONE: GRADE LEVEL: AGE: BIRTHDATE: PARENT OR GUARDIAN INFORMATION: ( Residence presumed to be that of the student.) PARENT/GUARDIAN: CELL PHONE: PLACE OF EMPLOYMENT: WORK PHONE: _ PARENT/GUARDIAN: CELL PHONE: PLACE OF EMPLOYMENT: WORK PHONE: INSURANCE COMPANY: POLICY # : EMERGENCY CONTACT # 1 NAME: _ PHONE: EMERGENCY CONTACT # 2 NAME: _ PHONE: IMPORTANT MEDICAL INFORMATION: (Please include any prescriptive drugs, allegories, or special health needs.) PARENT/GUARDIAN SIGNATURE: STUDENT SIGNATURE: DATE: DATE: This form must be kept with school officials at all times during a school trip. The form is filled out once per year and may be used for multiple activities. Page 6
OUT OF TOWN VOLUNTARY ACTIVITY PERMISSION FORM This consent form is to be signed only after understanding and agreeing to the information below. If all forms are not completed and returned prior to the school trip, the student will not be permitted to participate and will remain at school in a supervised activity or class. Group Activity: Date of Activity: Destination: Purpose of Activity: Departure Time: Sponsor In Charge: Arrival Time: Number of Chaperones: Cost Per Student: Mode of Transportation: Other: Hotel Name, Address and Phone: Risk Related Activity: Amusement /Theme Park Activity: Beach or Ocean Walking activities--no swimming/wading allowed: Other Supervision: Students will be directly supervised by adults on this trip at all times: Students will be directly supervised by adults on this trip at all times with the following exception: The principal, superintendent/ designee, or board of education reserves the right to cancel the activity. Should cancelation be based on insufficient participation or funds, the school district cannot guarantee reimbursement. It is strongly recommended that you personally review any tour company s or commercial carrier s contract, including its stated refund policies, BEFORE your child signs up or pays for the trip. Socorro Independent School District cannot be responsible for reimbursement to parents or students of money submitted as advance payment (i.e. shows, musical, concert) for any activity that is canceled. Parents/Guardians will be notified of any significant change in plans prior to the activity. I also understand that the trip may include amusement activities and participation in any amusement activities will expose my child to some risk of injury or even death. I have read and understand the description of the field trip (attached) and authorize my child to participate in the planned components of the field trip to the extent indicated by my signature below. I also understand the participation will be off school property. Parent Permission: Participation in all aspects of this trip Participation in all aspects of this trip; except the amusement and theme park activities or other, Participation in all aspects of trip, except water related activity. I give permission for my son/daughter (name): to participate in this activity. I have proved a completed, signed medical release form and have read rooming guidelines on page 9, and discipline and consequences beginning on page 4. Parent Signature: Date: Pupil Agreement While participating in this field trip, I will accept responsibility for maintaining good conduct, appearance, and will follow directions at all times. Pupil Signature: Date: Page 7
Release of Liability for Student Participation in School-Sponsored Trip(s) Via Alternative Transportation Name of Activity: Grade Level/Group Attending: Date(s) of Activities Departure: Return: Destination: City, State: _ I desire that my son/daughter be allowed to participate in the activities and travel to and from the activities of the group listed above. Although school transportation may be provided to and from the activities, I desire that my son/daughter be allowed to participate in and travel to and/or from the activities via an alternative mode of transportation. This alternative mode is strictly limited to travel to and/or from the activity with my son s/daughter s parent or legal guardian or by use of his or her personal legal driver s license. Students are not permitted to ride with other students unless they are siblings. Socorro Independent School District will not allow any other alternative mode of transportation. I fully understand and my son/daughter fully understands that transportation to and from the events attended by the group listed could create risk to the health or safety of my son/daughter. I, the undersigned, assume full and complete responsibility for any injury or accident that may occur to my son/daughter while traveling to or from the activities in transportation not provided by the District. In consideration of Socorro Independent School District allowing my child to participate in the activities of the above-referenced group and other good and valuable consideration, the receipt of which is acknowledged, I hereby release and waive all claims that I or my son/daughter may have against the Socorro Independent School District, its Board of Trustees, employees, agents, and representatives resulting, in whole of part, from my son/daughter traveling to and from the events attended by the group listed above while traveling in transportation not provided by the District. The release and waiver shall be binding on my heirs, legatees, administrators, and assigns. Printed Name of Parent/Guardian: Signature of Parent or Legal Guardian: Date: Printed Name of Student: Signature of Student: Date: Sponsor/Coach Signature: Date Approved: Page 8
Overnight Group Trip Request General Information: School: Organization: _ Sponsor: Date and Time of Departure: Date and Time of Return: Trip Destination: Total Number of Days on Trip: Please include detailed itinerary Total Number of School Days to be missed: Total Number of Students: Total Number of School Sponsors: Total Number of Parent Chaperones: (Ratio minimum is 25 to 1) Mode of Transportation (check all that apply) School Owned Van Air Commercial/Charter Bus Other Who is making trip arrangements: Which Travel Company is being used: Are they on the district vendor list? Yes No Item Total Cost Company Name Vendor No. Ground Transportation Airfare Hotel Meals Entry fees Park Admission Parking Fees Other (Please specify) Trip Total Page 9
Cost per Student: Cost per Adult: Total Amount of Student Out-of-pocket expenses: Total Amount of Adult Out of-pocket expenses: Please itemize out-of-pocket expenses: If trip was not included in the District s budget, explain in detail how and by whom funds will be raised. Note: All fund raising must have prior approval to trip approval. Please attached approved fund raising forms TRIP JUSTIFICATION Purpose of Trip: How does this trip reinforce the curriculum? Who is the sponsoring organization for this event/trip? How was the organization selected to participate? Open enrollment Invitation Audition Other (Please explain) Clearances Sponsor: Date: Campus Principal: Date Department Director: Date: Curriculum Department: Date: Administrative Services Department: Date: Superintendent or Designee: Date: Page 10
Investigation Procedures Flow Chart Incident occurs Sponsor becomes aware Sponsor contacts appropriate administrator Sponsor investigates Witness forms completed Contact parents Contact police and CPS Sponsor completes SISD Incident Report Sponsor updates administration and parents Turn in forms the next business day to Administrators Page 11
Investigation Procedures and Consequences Based on the Student Code of Conduct Coaches, athletic trainers, directors, sponsors and district employee chaperones have specific responsibilities when supervising students on district approved trips. Some basic information has been included on the Parent Permission Form. The content presented herein addresses specific investigation procedures and forms that the district employee should use when an incident occurs. There is also information about the Student Code of Conduct and a requirement for coaches/sponsors to acknowledge specific consequences for those students in their programs who commit a Level Ill or IV offense. Investigation Procedures Use Administrative Services Report Form 1. Steps 2-8 shall be completed within two hours of when coach and/or sponsor become aware of the incident. 2. Start writing a specific timeline of events as soon as you become aware of an incident or problem. 3. Report problem or incident to a campus or department administrator or lead staff member on the trip. 4. Report the problem or incident immediately to campus principal (Cell # ) and to Ron Durkes, Athletic Director (Cell # ) or Nellie Ponikvar, Fine Arts Director (Cell # ), or academic coordinator (Cell # ), or CTE Facilitator (Cell # ). 5. Has a law been broken? Yes No Uncertain 6. If a law has been broken, immediately report the problem to the appropriate law enforcement authority. 7. If there is an injury to a student by an adult, notify Child Protective Services (CPS) within 24 hours of incident 8. Divide the involved students among coaches and trip administrators and begin interviewing each student individually. Have each individual complete the witness information form. In every instance student safety must be ensured and each student must be treated humanely and respectfully. Use incident report: Witness Information Form 9. Contact parents immediately and reassure them of the condition of their child. 10. Do not promise confidentiality or anonymity under any circumstances. 11. Refer public information requests by the media, parents, or any other person to Daniel Escobar, Director of Public Relations. 12. Complete the incident report within 24 hours following the incident and give packet copies to the campus administration and the departmental supervisor on the next business day. 13. Incident report copies will be given to appropriate superintendent s cabinet member by respective campus and departmental administrators immediately upon receipt. Page 12
Incident Report Form Please print name of person completing form: Date of Incident: Time of Incident: am/pm Location of Incident: Campus Name: Department: Incident Summary :(Include: Who reported the incident? Date and time incident was reported. What took place? List all names of persons involved. Was there any evidence or were there any witnesses?) Name(s) of Sponsor(s) and chaperone(s) in charge: List the names of all sponsors and chaperones on the activity: Who was in charge of supervising the students at the time of the incident? (List names and titles, if applicable) List witnesses to the incident. (Use back of form if necessary. Obtain written statements from witnesses and include with this report.) Name, age & grade: Name, age & grade: Name, age & grade: Name, age & grade: What disciplinary action was taken? (Provide a report on what action was taken to ensure student safety and compliance with the Student Code of Conduct.) Please give date and time when the principal was contacted: Please give date and time when the appropriate district administrator contacted: Please give date and time when the local authorities contacted: Please provide the police case number if applicable: Please give date and time when the parents were contacted: Please give date and time when parents and administrators were updated: Signature of person completing report: Date completed: Phone Contact information: Page 13
Witness Information Form Student Name: Student ID: Campus: Program/Sport: Date of Incident / Offense: Location of Incident/Offense: Provide a summary of what took place with as many details as possible. Include: What took place; where it took place; who was involved; what time it did take place; any other information. Witness Signature Date My signature above certifies that the information I have provided is true to the best of my recollection and ability. Page 14