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REGION USE ONLYStamp Date ReceivedFIELD TRIP REQUEST PACKET(All forms in this packet must be completed)PRE-APPROVED BY:BOARD POLICY 2340 FHSAA9/5/2016DATEPERMISSION IS REQUESTED TO PARTICIPATE IN A FIELD TRIP.In-County Out-of-CountyTropical Park, St. Thomas University, Larry & Penny Park Out-of-State Out-of-Country 7900 SW 40th St, Miami, FL 33155; 16401 NW 37th Ave, Miami Gardens, FL 33054; 2451 SW 184th St, Miami, FL 33177DESTINATION ADDRESS09/09/2016; 09/17/2016; 9/23/2016; 10/07/2016; 10/20/201609/09 (1pm); 09/17(4:30 am); 9/23 (12pm); 10/07 (1pm); 10/20 (7am)DATES OF TRIP :(Include departure/return time) FROM TOCross CountryNAME OF SCHOOL GROUP (Band, Debate, etc.)1NAME OF SCHOOL GROUP SPONSORSPONSOR'S SIGNATURE1818Number of Students in GroupNumber of Students Participating in Trip 0N/ACost to Each StudentProvision for Those Unable to PayN/AMeans of Funding Trip1 # of Parents0 Total # Chaperones1# of Teachers1Additional Personnel*(*Paraprofessional Assistant, Nurse, Interpreter for the Deaf and Hard of Hearing, etc., are not to be counted as chaperones; however, they are responsiblefor supervising the student to which they are assigned.)PARENT PERMISSION SLIPS for participating students found in this packet must be on file in the Office of the Principal prior to the field trip.Students participating in FHSAA, GMAC, and MSAP water sports such as swimming and water polo are NOT required to complete a WaterRelated Field Trip Packet (FM-6614) and/or meet the swim test requirement.Cross Country CompetionPURPOSE FOR TRIP (Include objective, invitation and itinerary)TRANSPORTATION:*Private Vehicle (Name of Driver)**Bus CompanyAirline (Name of Carrier)Other (Specify)*Valid Driver's License verified? Yes No By Whom?(Private Vehicle Only)**Approved Private School Bus and Chartered Bus vendor verified by using the Department of Procurement Management Services websiteat http://procurement.dadeschools.net/field trips.asp A printed copy reflecting vendor approval must be attached for review.Mater Lakes AcademyPRINCIPAL’S SIGNATURE SCHOOLREGION SUPERINTENDENT DATE(Return to school for submission to School Operations, Division of Athletics, Activities and Accreditation, if applicable) FORWARD ONE COPY OF THIS PAGE TO THE CAFETERIA MANAGER OF YOUR SCHOOL. FOR IN-COUNTY OR PRE-APPROVED TRIPS, FORWARD ONE COPY OF THIS PACKET TO THE REGION FOR REVIEW. FOR OUT-OF-COUNTY (NOT PRE-APPROVED), THIS PACKET MUST BE FORWARDED TO THE REGION FOR REVIEW AND APPROVAL. FOR OUT-OF-STATE (NOT PRE-APPROVED) AND OUT-OF-COUNTRY TRIPS, THIS PACKET MUST BE FORWARDED TO THE REGION ANDTHE DIVISION OF ATHLETICS/ACTIVITIES AND ACCREDITATION (MAIL CODE: 9723) FOR REVIEW AND SUBMISSION FOR BOARDAPPROVAL.SCHOOL OPERATIONS, DIVISION OF ATHLETICS/ACTIVITIES AND ACCREDITATION USE ONLYAssistant SuperintendentDateDeputy Superintendent/Chief Operating OfficerDateFM-2431 (Rev. 08-16)
Board Policy 2340APPROVED OUT-OF-COUNTY/OUT-OF-STATE TRIPS*2016-2017A. CLUBS AND ORGANIZATIONS AFFILIATED WITH NATIONAL 16.17.18.19.20.American Automobile Association (AAA) School Safety PatrolBusiness Professionals of America/Career Education Clubs of Florida (BPA/CECF)Distributive Education Clubs of America (DECA), an Association for Marketing StudentsFamily, Career and Community Leaders of America (FCCLA)Fine Arts: Alliance for Young Artists and Writers Scholastic Art Awards, Florida Art Education Association Conference,Florida Music Educators Association Conference, International Thespian Society, Music Educators NationalConference, National Art Education Association, National Dance Education Organization, Southeastern TheatreConferenceFuture Business Leaders of America-Phi Beta Lambda, Inc. (FBLA)Future Educators of America (FEA)Health Occupations Students of America (HOSA)Junior State of America (JSA)National Academy Foundation (NAF)National Forensic League, Florida, Forensic League, Catholic Forensic LeagueNational Youth Crime WatchSkillsUSASpecial OlympicsSouthern Association of Student Councils (SASC)Student African American Brotherhood (SAAB)Student Against Destructive Decisions (SADD)Technology Student Association (TSA)The National FFA Organization (FFA)United States Department of Agriculture (USDA) AmbassadorsB. CURRICULUM/ACTIVITIES - RELATED .16.17.18.Advanced academic/gifted student contestsClose-Up ProgramCollege and University ToursColumbia Scholastic Press Association Convention, Columbia UniversityIngram African School Alliance Program (IASA)Junior Reserve Officers’ Training Corps (JROTC)The Junior Cadet Leadership Challenge (JCLC) Summer Camp for JROTCMagnet Programs (Theme-based)Music groups, visual art exhibitions, theatrical groups, dance troupes, speech and debate teams, cheerleadercompetitions and festivalsMuseums, Zoological Centers and Nature PreservesOdyssey of the MindNational High School Model United Nations (NHSMUN)Sea Camp (Big Pine Key, FL); John Pennekamp State Park (Key Largo, FL)State and national academic conferences, fairs, competitions and tournamentsState and national invitational forensic tournamentsThe African Sisters School ProjectThe Read to Lead ProgramYearbook SeminarsC. GENERAL INTEREST ACTIVITIESBusch Gardens1.2.Busch Gardens Grad Nite/Universal Studios Grad Bash (for high school seniors only)3.Cape Canaveral4.Disney Animal Kingdom5.Epcot Center6.Events sanctioned by the Florida High School Athletic Association (FHSAA)7.Everglades National Park8.Related performing and visual arts events (e.g., New York, NY; Los Angeles, CA)9.Related historical environs and special events (e.g., Atlanta, GA; Boston, MA; Chicago, IL; New Orleans, LA; New York,10.11.12.***NY; Philadelphia, PA; Williamsburg and Jamestown, VA; Los Angeles, CA; Seattle, WA; Washington, DC; Eatonville, FL;St. Augustine, FL; Tallahassee, FL; Tampa, FL)Sea WorldBroward and Monroe County sites/eventsUniversal Studios/Islands of Adventure (EXCLUDING Halloween Horror Nights – September 16 – October 31, 2016)Pre-approval does not indicate that funding is supplied.Trip designations for these events may change yearly. Trips outside of the United States require School Board approval. School sponsoringstudent travel outside the United States must complete the United States Government Travel Registration form on line.FM-2431 (Rev. 08-16)
MIAMI-DADE COUNTY PUBLIC SCHOOLSFIELD TRIP ROSTERINSTRUCTIONSList all eligible student participants. Those eligible students who are not participating in the field trip should be indicated byan asterisk (*).Mater Lakes AcademyNAME OF SCHOOLCross CountryNAME OF SCHOOL GROUPTropical Park, St. Thomas University, & Larry & Penny Thompson Memorial ParkDESTINATIONDATE(S) OF TRIP:09/09/2016; 09/17/2016; 9/23/2016; 10/07/2016; 10/20/201609/09/2016; 09/17/2016; 9/23/2016; 10/07/2016; 10/20/2016FROM TOPRINCIPAL’S SIGNATURE DATENAME OF STUDENTID #GRADE1.Romina Aguirre0094669112.Sundip Singh0489856103.Shaun Cruz0202625104.Daniela Martinez0110463105.Bryan Vega015966210Nicholas Parra0177387107.Alejandro Perez0046869118.Christian Mira015786510Isabella 010Jose Chio044045810Andres TUDENT ADDRESSTELEPHONENUMBER19.20.Page ofFM-2431 (Rev. 08-16)
NAME OF STUDENTID #GRADESTUDENT 0.31.32.33.34.35.36.37.38.39.40.Page ofFM-2431 (Rev. 08-16)
MIAMI-DADE COUNTY PUBLIC SCHOOLSFIELD TRIP CHAPERONE AND ACCESSIBILITY PERSONNEL LISTINSTRUCTIONSChaperones must be 21 years of age or older. List below all persons who will serve as chaperones, includingM-DCPS employees. Also, please list accessibility personnel (Paraprofessional Assistant, Nurse, Interpreter forthe Deaf and Hard of Hearing). Any person who is not employed at the school sponsoring this trip must haveprior clearance from the M-DCPS School Volunteer Program at Level I or Level II as appropriate for the trip (listthe volunteer number in the space provided).Mater Lakes AcademyNAME OF SCHOOLCross CountryNAME OF SCHOOL GROUPTropical Park (7900 SW 40th St, Miami, FL 33155); St. Thomas Univ. (16401 NW 37th Ave, Miami Gardens, FL 33054); Larry & Penny Park (2451 SW 184th St, Miami, FL 33177)DESTINATION09/09/2016; 09/17/2016; 9/23/2016; 10/07/2016; 10/20/2016DATE(S) OF TRIP: FROMNAME1. Kevin2. JoseDrennanMorales09/09/2016; 09/17/2016; 9/23/2016; 10/07/2016; 2-418-0162947694M787-643-8821VOLUNTEERLEVELPLEASE INDICATE WHETHERIT IS A CHAPERONE ORACCESSIBILITY PERSONNEL*3.4.5.6.7.8.Alternate Chaperone9.Alternate Chaperone10.*(Paraprofessional Assistant, Nurse, Interpreter for the Deaf and Hard of Hearing, etc., are not to be counted as chaperones; however, they are responsiblefor supervising the student to which they are assigned.)The sponsor’s and principal’s signatures below indicate that the volunteer information has beenverified and that all volunteers listed are cleared at Level II for overnight field trips that involvehotel/overnight accommodations and at least Level I for all other field trips.Sponsor’s Signature09/05/2016DatePrincipal’s SignatureDateRegion Superintendent’s Signature Date(For overnight field trips that involve hotel/overnight accommodations)FM-2431 (Rev. 08-16)
Division of Athletics, Activities and AccreditationMIAMI-DADE COUNTY PUBLIC SCHOOLSPARENT PERMISSION FORM -- FIELD TRIPField trips are not mandatory. They are designed to enhance curriculum, to encourage student participation in extra-curricular activities, andto serve as community service projects.SECTION I. IDENTIFYING INFORMATION09/05/2016Mater Lakes AcademySCHOOL DATESTUDENT'S NAME I.D. NO. GRADE/HRSECTION II. NOTIFICATION TO PARENTKevin DrennanMLA Cross Countryis planning a field trip fortoTropical Park, St. Thomas University, Larry & Penny ParkSchool Group Sponsor NameName of School GroupDestinationCross Country CompetitionsThe purpose of the trip isXTRANSPORTATION: Private VehicleBus Airline OtherName of CarrierKevin Drennan & Jose MoralesThis trip will be chaperoned byPlease Specify0Cost to each student (Total Number of Chaperones)I understand that if I am unable to pay for the cost of this trip, and I want my child to participate, where appropriate, my child will be given anopportunity to raise funds through authorized fund-raising activities, or be given assistance in identifying another funding source. (This provision doesnot apply to activities not directly related to classroom instruction, e.g., Grad Nite, football games, banquets.)09/09 (7pm); 09/17(12pm); 9/23 (6pm); 10/07 (7pm); 10/20 (2pm)09/09 (1pm); 09/17(4:30 am); 9/23 (12pm); 10/07 (1pm); 10/20 (7am)DATE(S) OF TRIP :(Include departure/return time) FROMTO--The above time schedule and/or personnel may be changed due to unforeseen circumstances. -PLEASE KEEP THE TOP PORTION FOR YOUR -------------------RETURN THE BOTTOM PORTION TO THE TEACHER.SECTION III. PARENT/GUARDIAN'S WRITTEN PERMISSION TO PARTICIPATE IN ACTIVITYI hereby give permission for my child Student I.D. No.(Child's Name)Tropical Park (7900 SW 40th St, Miami, FL 33155); St. Thomas Univ. (16401 NW 37th Ave, Miami Gardens, FL 33054); Larry & Penny Park (2451 SW 184th St, Miami, FL 33177)to participate in the field trip to(Destination)09/09 (7pm); 09/17(12pm); 9/23 (6pm); 10/07 (7pm); 10/20 (2pm)09/09 (1pm); 09/17(4:30 am); 9/23 (12pm); 10/07 (1pm); 10/20 (7am)DATE(S) OF TRIP :(Include departure/return time) FROMTOI have completed the EMERGENCY CONTACT INFORMATION in Section IV (see below).SIGNATURE OF PARENT/GUARDIAN DATESECTION IV. EMERGENCY CONTACT INFORMATION1. Name of parent/guardian2. Parent/Guardian Phone No(s). HomeBusinessCell3. In case parent/guardian cannot be reached, please contact: Relationship Telephone No.4. Please list any insurance policy covering your child Policy No.5. Physician's Name Telephone No.5. Only if applicable, complete the following:FM-4573E Rev. (09-09) Clear Forma. My child has the following medical problem:b. My child takes the following medications regularly:(Proper Medical form #2702 is on file at the school)c. My child has the following allergies:I AUTHORIZE MEDICAL TREATMENT FOR MY CHILD IN CASE OF ACCIDENT OR ILLNESS WHILE ON THE TRIP.PARENT/GUARDIAN SIGNATURE DATEFM-2431 (Rev. 08-16)
FOR SECONDARY SCHOOLS ONLY:SECTION V. TEACHER NOTIFICATION OF ACTIVITYTropical Park; St. Thomas Univ.; Larry & Penny Park09/09; 09/17; 9/23 10/07;10/2009/09; 09/17; 9/23 10/07;10/20Field Trip Destination Dates of Trip: FROM TOKevin DrennanMLA Cross CountryName of School GroupSchool Group Sponsor NamePERIOD 1PERIOD 5PERIOD 2PERIOD 6PERIOD 3PERIOD 7PERIOD 4PERIOD 8FM-2431 (Rev. 08-16)
MIAMI-DADE COUNTY PUBLIC SCHOOLSFORMULARIO DE AUTORIZACION PARA PADRES - EXCURSIONESLas excursiones no son obligatorias. Las mismas son planificadas a fin de realzar el programa de estudios, alentar laparticipación de los estudiantes en actividades extracurriculares y servir como proyectos de servicios a la comunidad.SECCION I. DATOS DE IDENTIFICACIONESCUELA FECHANOMBRE DEL (DE LA) ESTUDIANTE NO. DE IDENTIFICACION GRADOSECCION II. NOTIFICACION A LOS PADRESplanea una excursión con aNombre del(de la) patrocinador(a)(Nombre del Grupo)(Destino)El propósito de la excursión esTRANSPORTE: Vehículo Privado ómnibus Aerolínea Otro(Nombre de la compañía)Esta excursión será supervisada por(Por favor, especifique)Costo por estudiante (Numero de Chaperones)Entiendo que si deseo que mi hijo(a) participe y no puedo pagar el costo de esta excursión, cuando sea posible, a mi hijo(a) se le dará la oportunidadde recaudar fondos mediante actividades de recolección de fondos o se le asistirá en la identificación de otras fuentes de recursos financieros (Estamedida no se aplica a las actividades que no se relacionen directamente con la instrucción que se realiza en las aulas, como por ejemplo, la noche delos graduados o “Grad Nite”, los juegos de fútbol y los banquetes.)FECHA:(Incluir hora de salida y llegada) DE A-- El horario o el personal pueden ser cambiados por circunstancias imprevistas -PARA QUE SE MANTEGA INFORMADO(A) POR FAVOR CONSERVE LA PORCION ---------------POR FAVOR DEVUELVA LA PORCION INFERIOR A LA ESCUELASECCION III. AUTORIZACION DE PADRES/TUTORES PARA QUE EL (LA) ESTUDIANTE PARTICIPE EN LA EXCURSIONLe doy la autorización para que mi hijo(a) No. de IdentificaciónNombre del (de la) niño(a)participe en la excursión aDestinoFECHA:(Incluir hora de salida y llegada) DE AHe llenado los datos SOBRE A QUIEN LLAMAR EN CASO DE EMERGENCIA de la Sección IV (a continuación).FIRMA DEL PADRE/DE LA MADRE O TUTOR(A) FECHASECCION IV. DATOS SOBRE A QUIEN LLAMAR EN CASO DE EMERGENCIA1. Nombre del padre/de la madre o tutor(a)2. No. de teléfono del padre/de la madre o tutor(a) Casa EmpleoCelular3. Si los padres o tutor(a) no pueden ser localizados, por favor comuníquense con Relación No. de teléfono4. Póliza(s) de seguro que cubren a su hijo(a) No. de Póliza(s)5. Nombre del médico No. de teléfono5. Llene lo siguiente solamente si aplica a su hijo(a):FM-4573E Rev. (09-09) a. Mi hijo(a) tiene el siguiente problema médico:b. Mi hijo(a) toma las siguientes medicinas con regularidad:(El correspondiente formulario medico 2702 está archivado en la escuela)c. Mi hijo(a) tiene las siguientes alergias:Clear AUTORIZOForm A QUE SE DE TRATAMIENTO MEDICO A MI HIJO(A) EN CASO DE ACCIDENTE O ENFERMEDAD MIENTRA SE ENCUENTRE EN ESTE VIAJEFIRMA DEL PADRE/DE LA MADRE O TUTOR(A) FECHAFM-2431 (Rev. 08-16)
MIAMI-DADE COUNTY PUBLIC SCHOOLSFÒM PÈMISYON - PWOMNADPwomnad pa obligatwa. Yo fèt pou amelyore kourikouloum nan, pou ankouraje elèv yo patisipe nan ekstra aktiviteakadernik, e pou sèvi kòm pwojè.SEKSYON I. IDANTIFYE ENFÒMASYONLEKOL DATNON ELÈV LA NO. I.D. NIVO ANE ESKOLÈ/ÈD TANSEKSYON II. NOTIFIKASYON POU PARANiap planitye yon pwornnad pou PonPwofesè/non pahvonèGwouplSijèDestinationBi pwomnad sa a seTRANSPÒTASYON: Machin Prive Bis Avyon LòtNon KonpayiEspesifyePwomnad sa a ap gen siveyan A chapewon L ap koute chak timoun(Pwofesè/ParanlToude - endike konbyen)Mwen konprann si rn pa ka peye pou pwornnad sa a, e mwen vle pitit mwen patisipe, lè li apwopriye, n ap otri pitit mwen an opòtinitepou li kolekte lajan atravè aktivite pou kolekte ton lekòl la otorize, oubyen nan bay asistans nan idantitye lòt sous pou fon. (rezèvasyonsa a pap aplike pou aktivite ki pa dirèkteman relate ak enstriksyon klas, pa egzanp, sware gradyasyon, jwèt foutbòl, bankè.)Dat N ap Derape Dat N ap Retounen--Le ki make anwo a e/oubyen moun yo kab chanje akoz yon sikonstans enprevi-SILVOUPLÈ KENBE POSYON ANWO A POU -------------------RETOUNEN POSYON ANBA A BAY PWOFESÈ A.SEKSYON III. PÈMISYON PARAN/GADYEN A LEIKRI POU PATISIEPE NAN AKTIVITEMwen bay pèrnisyon pou pitit mwen No. I.D.(ATon Timoun nan)patisipe nan pwomnad(Destination)Dat N ap Derape Dat N ap RetounenMwen ranpli ENFÒMASYON KONTAK IJANS la nan Seksyon IV (wè anba a).SIYATI PARAN/GADYEN DATSEKSYON IV. ENFÒMASYON KONTAK IJANS1. Non paran/gadyen2. No. Telefòn paran/Gadyen (yo) Kay: Biznis telefòn celulair3. An ka nou pa ka jwenn paran/gadyen an, silvouplè kontakte Relasyon ak elèv la No. Telefòn4. Silvouplè site nenpòt asirans ki kouvri pitit on No. Kontra5. Non dokte li No. Telefòn5. Ranpli hy ki suiv yo, sèlsi yo aplikab:FM-4573E Rev. (09-09) Clear Forma. Pitit mwen an gen pwoblèm medikal sa yo:b. Pitit mwen an pran medikaman sa yo regilyèrnan:(Bonjan fòm medikal #FM-2702 nan dokiman lekòl la)c. Pitit mwen an gen alèji sa yo:M OTORIZE TRETMAN MEDIKAL POU PITIT MWEN AN KA AKSIDAN OUBYEN MALADI PANDAN Ll NAN PWOMNAD LA.SIYATI PARAN/GADYEN DATFM-2431 (Rev. 08-16)
3. College and University Tours 4. Columbia Scholastic Press Association Convention, Columbia University 5. Ingram African School Alliance Program (IASA) 6. Junior Reserve Officers' Training Corps (JROTC) 7. The Junior Cadet Leadership Challenge (JCLC) Summer Camp for JROTC 8. Magnet Programs (Theme-based) 9.
