PEARL RIVER COUNTY SCHOOL DISTRICT FIELD TRIP REQUEST FORM Date Request Made:________________________ Teacher/Sponsor’s Responsibilities: Secure permission form for each student going on the field trip, have name of parent/guardian to notify in case of an emergency, have two telephone numbers for each student, secure mode of transportation (all permit forms must be submitted to the Transportation Director one week prior to trip), list of students actually leaving with you turned into the office the morning of the trip. (Check roll once transportation is loaded and send list of students to the front office before leaving the campus). Teacher/Sponsor accepting responsibility:____________________________________ Class or Club:__________________________

Date of Trip:____________________

Justification of Trip:_____________________________________________________ Destinations & Route (list all places you will be visiting, include meal plans):_______ _____________________________________________________________________ _____________________________________________________________________ Mode of Transportation (bus, school car), file for permit at least one week prior to trip: ____________________________________ Date,

Time Leaving:____/____/____

Date, Time Returning:____/____/____

____a.m., p.m. ____a.m., p.m. Number of Students:_____

Names of Chaperones:_____________________

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Date:___________________ Approved:__________________ Denied:____________ ____________________________________ Principal Form #17

_________________________________ Superintendent of Education Revised 5/23/2006