Overnight Field Trip Request Form - Boston Public Schools

Overnight Field Trip Request Form (This form is submitted to the Principal/Headmaster and is kept on file in the school office. In addition, notify the appropriate Network Superintendent and the Department of Global Education of your plans by faxing or emailing as a PDF the following documents : 1) Overnight field Trip Request Form signed by the principal/headmaster, 2) day-by-day trip itinerary, 3) list of student participants and their grades in school, and 4) if applicable, your flight or train itinerary. Please call or email to ensure these documents have been received by all parties.

School Information

School:

Responsibility Center #:

Date Submitted:

Trip Overview

Number of Students: Number of Chaperones:

(Supervision: maximum ratio 10:1; For students with disabilities, the ratio of staff to students must be at least the same as the ratio mandated in their IEPs for their classes.)

Field Trip Category:

Destination:

Dates of Trip:

Overview of Trip (Educational Purpose):

Accommodation Information

Accommodation Name, Address and Phone Number

Program Provider Information (if applicable)

Program Provider:

Program Provider Contact Person:

Program Provider Telephone Number:

Program Email:

Itinerary

Please attach detailed day-by-day itinerary.

Lead Chaperone

Lead Chaperone/Trip Organizer:

Role in School:

Superintendent’s Circular #CAO-24, 2015-2016 September 1, 2015 of 25

Lead Chaperone Phone # (prior to trip)

Lead Chaperone Cell Phone # (during the trip) _____________________________________

Lead Chaperone Email: _______________________________________________________

Other Chaperones/ Roles in School/ Phone Numbers on Field Trip:

Student Participants:

Please attach a list of students attending the trip and the grades they are in.

Transportation Information:

Staff are not permitted to drive students. Privately owned vehicles, vehicles from non-approved vendors or leased vehicles are not to be utilized to transport students to and from field trips, except in the case of a bona fide emergency. Staff who utilize their own vehicles risk being legally liable. Please refer to TRN-3 for regulations regarding field trip transportation.

Method of Transportation:____________________________________________________

Transportation Company: (For bus transportation, only BPS approved vendors may be

used regardless of how the trip is paid for. See TRN-3 for list.)

___________________________________________________________________________

Contact Information: (phone and address)__________________________________________

Departure Location and Time:___________________________________________________

Return Location and Time:______________________________________________________

*(if applicable, attach detailed train or flight information) Funding Sources: Total Cost $__________Funding Source________ Grant Number______________________

BEDF Account Code/Description. ______________________/________________________

Approved by: _____________________________________________ ______________ Principal/ Headmaster or Sponsoring District Department Date Your signature indicates that all policies outlined in this circular regarding day field trips will be followed.

EMERGENCY ACTION PLAN (EAP) Procedures for Calling 911 on a Field Trip


Do Not Leave the Injured Person Alone or Without an Adult Present

1. REMAIN CALM. This helps the operator receive your information. 2. DIAL 911. Remember you may need to access an outside line first. 3. My name is . “I am a (your role) in the

Boston Public Schools.” 4. I need paramedics now. 5. My exact address is _______________________ . 6. There is a person with a (type/location of injury) _________________ injury. 7. The person’s name is ______ and he/she is ______ years old. 8. The person is located at _______________ which is on the (North/South/East/West) _________________ side of the facility. 9. I am calling from (telephone number) ___________ _______ . 10. (Name) ____________ _____ will meet the ambulance. 11. Don’t hang up. Ask for the information to be repeated back to you and answer any questions the dispatcher may have. Hang up the phone when all of the information is correct and verified. 12. Wait with person until EMS arrives. 13. Paramedics will take over care of the person when they arrive. A chaperone must accompany any injured student in the ambulance and remain with the student until the Parent/Guardian arrives. 14. Call the Department of Global Education (DGE) regarding incident immediately. Call the

Parent/Guardian with the support of the DGE. The DGE will assist in contacting the necessary district personnel. File an Overnight Program Incident Report and Overnight Incident Log.

Department of Global Education: (617) 635- 9157 (contact DGE for 24/7 emergency number) Principal/Headmaster Phone Numbers: Principal Leader: Department of Safety Services: (617) 635-8000 Additional Phone Numbers:

THIS PAGE IS INTENTIONALLY BLANK


Parental Authorization for Overnight Field Trip Directions:

BPS Staff: 1) Use one form per trip. 2) Complete the School Portion of form.

3) Duplicate one form per student. 4) Send a copy home for parent and student signatures. 5) During the field trip, the signed, original form must be carried by the lead chaperone, copies by other chaperones, and a photocopy must be left on file in the school office.

Students: 1) Complete the “Student Agreement” section. Parent / legal guardian, if student is under 18 years of age, or student, if at least 18 years old:

1) Complete the “Authorization and Acknowledgement of Risks” and “Medical Authorization” section. 2) Complete the “Important Medical Information Form” and “Medication Administration Form.”

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School Name: Student Name:

Date(s) of Trip: Destination:

Purpose(s):

List of Activities:

Supervision: (Check One.) □ Students will be directly supervised by adult chaperones on this trip at all times. □ Students will be directly supervised by adult chaperones on this trip with the following exceptions:

Mode of Transportation: (Check all that apply.)

□ walking □ school bus □ MBTA □ Other ______________________ Students will leave from: ______________________________at ____________________. (where) (time) Students will return to: ________________________________at about _______________. (where) (time) Chaperone(s) in Charge: ___________________________________________________________________ Chaperone/Student Ratio: _____________________ (maximum ratio 10:1)

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While participating in this field trip, I understand I will be a representative of BPS and my community. I understand that appropriate standards must be observed, and I will accept responsibility for maintaining good conduct and abide by school based rules and the Boston Public Schools’ Code of Conduct. _________________________________________ ______________________ Student Signature Date


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AUTHORIZATION AND ACKNOWLEDGMENT OF RISKS I understand that my/my child’s participation in this field trip is voluntary and may expose me/my child to some risk(s). I have read and understand the description of the field trip (on the front page of this form) and authorize myself/my child to participate in the planned components of the field trip. I assume full responsibility for any risk of personal or property damages arising out of or related to my / my child’s partic ipation in this field trip, including any acts of negligence or otherwise from the moment that my student is under BPS supervision and throughout the duration of the trip. I further agree to indemnify and to hold harmless BPS and any of the individuals and other organizations associated with BPS in this field trip from any claim or liability arising out of my/my child’s participation in this field trip. I also understand that participation in the field trip will involve activities off of school property; therefore, neither the Boston Public Schools, nor its employees nor volunteers, will have any responsibility for the condition and use of any non-school property. I understand that BPS is not responsible for my/my child’s supervision during such periods of time when I/my child may be absent from a BPS supervised activity. Such occasions are noted in the “Supervision” section in this agreement. I state that I have/my child has read and agree(s) to abide by the terms and conditions set forth in the BPS Code of Conduct, and to abide by all decisions made by teachers, staff, and those in authority. I agree that BPS has the right to enforce these rules, standards, and instructions. I agree that my/my child’s participation in this field trip may at any time be terminated by BPS in the light of my/my child’s failure to follow these regulations, or for any reason which BPS may deem to be in the best interest of a student group, and that I/my child may be sent home at my own expense with no refund as a result. In addition, chaperones may alter trip activities to enhance individual and/or group safety.

MEDICAL AUTHORIZATION I certify that I am/my child is in good physical and behavioral health and I have/my child has no special medical or physical conditions which would impede participation in this field trip. I agree to complete in its entirety the attached “Medical Information Form” and “Medication Administration Form” found on last pages of this Authorization. I authorize the release of the information given in these forms above to chaperones and other school staff in order to coordinate services and understand that chaperones will consult with the school nurse about each student's health so they will be in the strongest position to support you/your child on this program. I agree to disclose to BPS any medications (including over-the counter/herbal) and/or prescriptions which I/my child shall or should take at any time during the duration of the field trip. In the event of serious illness or injury to myself/my child, I expressly consent by my signature to the administration of emergency medical care, if in the opinion of attending medical personnel, such action is advisable. Further, when necessary, I authorize the chaperones to act on behalf of myself/my child while participating in the above described trip including the admittance to and release from a medical facility _____________________________________________________________________________________________________________

SIGNATURES If the applicant is at least 18 years of age, the following statement must be read and signed by the student. I certify that I am at least 18 years of age, that I have read and that I understand the above Agreement, and that I accept and will be bound by its terms and conditions. ________________________ Student Signature Date If the applicant is under 18 years of age, the following statement must be read and signed by the student’s parent or legal guardian. I certify that I am the parent and legal guardian of the applicant, that I have read and that I understand the above Agreement, and that I accept and will be bound by its terms and conditions on my own behalf and on behalf of the student. I give permission for: _______________________________________________________________ to participate in all aspects of this trip. (student name) __________________________________________________________ Parent/Guardian Signature/s Date The student, if at least 18 years of age, or parent/legal guardian must complete the information below: Print Parent/Guardians First and Last Name/s:___________________________________________________________________________ Address:_________________________________________________________________________________________________________ Telephone: (Cell) _____________________________(Home)_____________________________(Work) ____________________________ Emergency Contact’s Name: (other than parent/guardian) __________________________________________________________________ Relationship to Student: _______________________________________________Emergency Contact’s Telephone #s: _______________


Medical Information Form (Students may be in new and unfamiliar situations when traveling, it is critical that this form is completed thoroughly and accurately so we may be in the best position possible to support you/your child.)

Student First and Last Name: Date of Birth:

Parent/ Guardian Name(s): Parent/Guardian Address: Telephone: (Cell)____________ (Home) ___________________ (Work)______________ Telephone: (Cell)____________ (Home) ___________________ (Work)______________ Emergency Contact Information: (other than parent/guardian) (1) ___________________________________ ___________________________________ Name Relationship to Student ____________________________________ Phone Number Other Contact Information (2) ___________________________________ ___________________________________ Name Relationship to Student ____________________________________ ___________________________________ Phone Number Other Contact Information

Primary Care Physician’s Name and Contact Information (in case of an emergency): Health Insurance Provider’s Name, Policy #, and Contact Information (in case of emergency): Insurance Provider Claim Instructions/Procedures (in case of emergency):


Student has the following health conditions and/or allergies of which BPS should be aware: Physical Health Conditions: Behavioral Health Conditions: (eg. Depression, anxiety, etc.) Allergies (food, medication, insects, plants, animals, ect.): Student takes the following medications (including over-the counter/ herbal) and/or prescriptions of which BPS should be aware. (Be sure to complete the Medical Administration Form): If medication is taken on an as-needed basis, specify the symptoms or conditions when medication is to be taken and the time at which it may be given again. Is there any factor that makes it advisable for your child to follow a limited program of physical activity? (i.e. asthma, recent surgery, heart condition, fear, etc.) If yes, specify the ways in which you wish his/her program limited. If the student has asthma, please attach the asthma action plan to this medical form. Further, is there anything on the itinerary that your child cannot or should not do?


Other than a yearly physical, is the student currently under a physician’s or other medical professional’s care (eg. social worker, therapist, etc.)? If yes, please detail the reason. Other than the yearly physical, has the student been under a physician’s or other medical professional’s (eg. social worker, therapist, etc.) care anytime in the last year. If yes, please detail the reason and dates of treatment. Please list any hospital, treatment center, surgical, psychiatric or urgent care visits within the last year: (Please specify the date, the reason, the physician or professional seen, and the length of stay.) Additional information of which BPS should be aware concerning student’s health: I authorize the release of the information given above to chaperones and other school staff in order to coordinate services and understand that chaperones will consult with the school nurse about each student's health so they will be in the strongest position to support you/your child on this program. ________________________________________________ ____________________ Student Signature, if at least 18 years of age Date _________________________________________________ _________________ Parent/Guardian Signature, if student is under 18 years of age Date * If necessary, attach doctor’s letter to this form. * If necessary, attach the asthma action plan to this form. * If necessary, attach copies that document student’s shots and immunizations to this form.


Medication Administration Form *Please send only essential medications with your student on this trip and include over-the counter/herbal

medications on this list.*

Student Name: 1. Name of Medication______________________________________________________ Time(s) to be taken _______________________________________________________ Reason for Medication _____________________________________________________ Side effects to be aware of/other information ___________________________________ 2. Name of Medication______________________________________________________ Time(s) to be taken________________________________________________________ Reason for Medication ____________________________________________________ Side effects to be aware of/other information ___________________________________ 3. Name of Medication _____________________________________________________ Time(s) to be taken _______________________________________________________ Reason for Medication ____________________________________________________ Side effects to be aware of/other information ___________________________________ 4. Name of Medication _____________________________________________________ Time(s) to be taken ________________________________________________________ Reason for Medication ____________________________________________________ Side effects to be aware of/other information ___________________________________ Additional Information/ Special Instructions: I authorize for my child to take the above medications on this trip. ________________________________________________ ____________________ Student Signature, if at least 18 years of age Date _________________________________________________ _________________ Parent/Guardian Signature, if student is under 18 years of age Date


NOTORIZED PARENT/GUARDIAN AIRLINE TRAVEL CONSENT FORM

The parties to this agreement are:

Parent/ Legal Guardian:

Full Name and Surname: (hereinafter referred to as “the Parent/ Guardian”) Physical Address: Contact Details: Child: (hereinafter referred to as “the Child”) Full Name and Surname: Birth Date: Traveling Guardian(s) and Contact Details: (hereinafter referred to as “The Traveling Guardians”) Full Name and Address:

1. I hereby authorize the Child to travel with the Traveling Guardians to the following destination: 2. The period of travel shall be from the ______________________________. 3. Should it prove to be impossible to notify the Parent/ Guardian of any change in travel plans due to an

emergency or unforeseen circumstances arising, I authorize the Traveling Guardian to authorize such travel plans.

4. Should the Traveling Guardian in his/her sole discretion (which discretion shall not be unreasonably exercised) deem it advisable to make special travel arrangements for the Child to be returned home due to unforeseen circumstances arising, I accept full responsibility for the additional costs which shall be incurred thereby.

5. I indemnify the Traveling Guardian against any and all claims whatsoever and howsoever arising, save where such claims arise from negligence, gross negligence, or willful intent during the specified period of this Travel Consent.

6. I declare that I am the legal custodian of the Child and that I have legal authority to grant travel consent to the Traveling Guardian of the Child.

7. Unless inconsistent with the context, words signifying the singular shall include the plural and vice versa. Signed at ___________________________________________ on the _______day of __________, 20____. Signature ________________________________________________________________ (Parent/ Guardian) Signature ____________________________ (Witness 1) Signature _______________________(Witness 2) *Witness signatures must be by independent persons and not by anyone listed on the Travel Consent form.

On this _____ day of ___________________, 20___, before me, the undersigned authority, personally appeared and proved to me through satisfactory evidence of identity, to wit, to be the person(s) whose name(s) is/are signed on the attached document and who signed in my presence.

Official Notary Signature: ___________________________________________________________________

Name of Notary Typed, Printed or Stamped: Commission Expires: ____


Overnight Programs Incident Report

A. Complete all Fields

School/s: Date of Report:

Country:

Incident Date and Time:

Reporting Chaperone:

B. Complete all Applicable Fields

Victim(s) Name(s)

Contact Information

Suspect(s) Name(s)

Contact Information

Witness(s) Name(s)

Contact Information

Where Event Occurred

Address

Illness/Injury/Event Description


C. Nature of Incident (check all that apply)

☐Injury ☐Equipment Failure ☐Behavioral/ Psychological

☐Illness ☐Missing/Separated Person ☐Natural Disaster

☐Physical Assault ☐Sexual Assault ☐Theft

☐Property Damage ☐Sexual Harassment ☐Fatality

☐Crime ☐Political Upheaval ☐Disease Outbreak

☐Other___________

D. Activity at Time of Incident (check all that apply)

☐Class time ☐Service ☐Home-stay ☐Free Time

☐Traveling ☐Fieldtrip ☐Camping ☐Hike/Jog/Walk

☐Swimming ☐Water Activity

☐Other _____________

E. Contributing Factors (Check all that apply)

☐Not disclosed in Medical Form ☐Sports/Recreation ☐Animal/Insect/Plant

☐Pre-Existing Condition ☐Alcohol/Drugs/Medication

☐Motor Vehicle ☐Weather/Terrain

☐Pre-Course Info ☐Orientation/Training

☐Political/Cultural/Language ☐Other____________


F. Action Taken Details

First Aid

When

By Whom

Type (ie. Medication,

CPR, etc.)

Emergency Evacuation

Visit Medical Facility

Name of Facility

Doctor/PA/Nurse

Reported Diagnosis

Medication Prescribed

Other


Emergency Contact

Person Notified?

☐Yes ☐ No

Name:

Date and Time Contacted:

Notes:

Department of Global

Education (DGE)

Contacted?

☐Yes ☐No

Name:

Date and Time DGE Contacted:

DGE Staff Person Contacted:

Notes:

Frontier Medex

Contacted?

☐Yes ☐No

Name:

Date and Time Contacted:

Case #:

Notes:

Local Authorities

Notified?

☐Yes ☐No

Date and Time Notified:

Organization:

Authority Name(s):

Notes:

Follow up Plan

Details:


G. Narrative (The story/What happened):

H. Analysis (Why did this happen? What were contributing factors to the incident? What might we

do to respond to this type of incident?)

Signature of Reporting Chaperone: __________________________________________________ File this Overnight Incident Programs Report along with any accompanying reports/documents from local law enforcement, medical professionals and/or International Programs Witness Report via email if possible OR as soon as circumstances permit. Turn in the original report to the DGE as soon as you return to Boston.

DEPARTMENT OF GLOBAL EDUCATION

2300 WASHINGTON ST., ROXBURY, MA 02119 • 617-635-9157


Overnight Programs Witness Report

Witness Statement of________________________________________________________ Phone Number: Address:

Description: I believe the contents in this statement are true. ___________________________________________ ___________ Signature Date


Overnight Programs Incident Log


FIRE PREVENTION AND SAFETY PRACTICES

Overnight Programs

Even while participating in out-of-school programs, emergency preparedness is essential. One way chaperones on overnight and international programs must be trained in is fire prevention, life safety and evacuation plans for the accommodations and venues where programs are conducted. Fire safety plans on overnight and international programs differ than the procedures set for our schools. The accommodation, the surrounding landscape and the fire safety supports as well as the standards and laws that regulate fire prevention may differ than what exists in Massachusetts. Below are steps to assist lead chaperones in creating a safety plan regardless of trip type, trip destination, accommodation type, or the fire prevention and support landscape. The steps below must be followed on all overnight and international programs:

I. Conduct A Fire Prevention Assessment

The lead chaperone must conduct a fire safety prevention assessment using the Fire Prevention and Safety Form (Attachment A) within 24 hours of arrival. Using the Fire Prevention and Safety Form, the lead chaperone shall formulate a plan for the evacuation of all persons on the trip in the event of a fire or other emergency. This plan shall include alternate means of egress and should be created in consultation with an accommodation staff person, and if applicable, the third party provider.

II. Prepare Chaperone Team on Fire Prevention Strategy

Based on the results from the Fire Prevention and Safety Form, the lead chaperone should ensure that each staff member receives and understands the fire prevention landscape and has instructions on the fire drill procedure created for the accommodation. Questions to review include:

A. What are the best means of egress in case of a fire? (Consider all rooms students and

staff are staying in and all places where the group may congregate. Use the hotel’s posted evacuation routes if applicable.)

B. Where is the designated meeting point? (This meeting point should be a safe distance from the building, but easy for the group to identify and locate.)

C. Who is responsible for each student? (Attendance must be taken; if chaperone ratios

permit, the lead chaperone should not be assigned to a group and should serve as contact person for emergency personnel.)

D. What are some hazards that students and chaperones should be aware of?

E. What happens in the case of a missing person?


III. Review Prevention Strategy with Students and Conduct a Fire Drill

The lead chaperone and the chaperone team will review the fire prevention strategy and conduct a fire drill (walkthrough) with the students within the first 24 hours of the trip. Conducting a fire drill (walkthrough) is important as participants are unfamiliar with the building.

Instructions for Fire Drills: Since each accommodation is different, each plan and drill will vary. Regardless of the accommodation, it is critical that a procedure is in place for evacuating the building, each chaperone knows his/her responsibilities, every student participates in the fire drill (walkthrough), and each person knows the meeting location when evacuated from the building. Please note: A fire drill as defined here is a walkthrough of the route the group will take to exit the premises in the event of an emergency. A few general instructions:

Evacuate immediately.

Do not use elevators during a fire evacuation.

Each student should walk to the designated meeting location outside of the building in a quiet and orderly manner.

Make sure all students know all possible exits from their area and that students know where the meeting location is outside of the building.

Fire drill plans must ensure adequate procedures for the emergency evacuation of students and staff with disabilities. (Have a staging location for students/staff with disabilities and make sure hotel/hostel personnel are also aware.)

Chaperones are responsible for students under their supervision and must take attendance.

Upon the evacuation of a building, no person or persons shall re-enter the building without the authorization of the lead chaperone. The lead chaperone, as a part of their fire drill procedures, must establish a command procedure for such evacuations.

IV. Conduct a Post-Fire Drill Debrief

After the fire drill, the chaperone team should set aside time to debrief. Record response on Attachment A.


Attachment A

Fire Prevention and Safety Assessment Form Directions: For each accommodation, please complete and upon your return, file this form with other documents you are mandated to keep such as student permissions slips. Legally, these documents must be kept on file for the current fiscal year plus three additional years after the field trip has occurred. Building: Lead Chaperone: Date of the Safety Prevention Assessment: Name/s of Staff and Their Titles Consulted for Assessment: (accommodation staff/ program provider staff) Outside the Building

List the possible hazards in the area. Can the accommodation be accessed by a fire department or emergency teams? YES NO Inside the Building

Equipment Does the building have fire alarms? YES NO Are there fire sprinklers? YES NO If yes, where are they located? Is there adequate lighting in the corridors? YES NO Are there clear exit signs? YES NO Are there fire alarm pull stations? YES NO Are the fire alarm pull stations visible and accessible? YES NO Are there fire extinguishers? YES NO If yes, where?


Are there smoke detectors in the corridors and in every room where participants are staying? YES NO Hazards

List the potential fire hazards at the site:

Are there notable fire hazards such as open fire doors, accumulated trash, blocked corridors, locked exit doors, blocked stairways, burned out exit lights or missing/broken fire equipment? YES NO Means of Evacuation/Egress

Does the facility have an evacuation plan for each room? (If not, be sure that when you conduct a fire drill (walkthrough) that you develop a plan for leaving the room.)

YES NO

What is the means of egress? Are there primary exits and alternate exits? YES NO

Note locations: Fire Drill/Walkthrough Plan: (Please record notes below.)

Post-Drill Debrief

Date and Time of the Fire Drill: ___________________________________________

Did the students and chaperones follow the procedures of the fire drill?

YES NO

If no, why not?

Based on this debrief, either inform the students of your findings for adjustments, or if necessary, conduct another fire drill. Once safety review and drill is completed, please sign below.

Signature of Lead Chaperone_________________________________________Date __________

Overnight Field Trip Request Form - Boston Public Schools

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