Field Trip & Activity Request Form

Field Trip & Activity Request Form

Instructions: Use this form to request permission for all field trips/activities not listed in the Calendar of Events. Submit the completed form to the Office of Student Services at least TWO weeks in advance of the trip. If the trip involves any time period between 7:45 am, Monday, and noon, Friday, while classes are in session, submit the form at least THREE weeks in advance.
Instructor/Supervisor Name*

First NameLast Name
Instructor/Supervisor Email*
Academic Term of Event*
Ex. Fall 2023/24
Is this request for a Class Field Trip?*

YESNO
Does this trip take place during an Academic Day?*

YESNO
Will you require multiple trips throughout the semester?*

YESNO
How many trips will you require approval for this semester?*

23456
How many courses will attend this trip?*

123
Course 1 Prefix & Number *
Ex. BIOL110
Course 1 Name*
Course 2 Prefix & Number *
Ex. BIOL110
Course 2 Name*
Course 3 Prefix & Number *
Ex. BIOL110
Course 3 Name*
Club/Organization (if non-academic trip)*
Sponsors/Volunteers*
Departure Date*

MonthDayYear
Date
Departure Time*

Hour Minutes

AM/PM Option
Return Date*

MonthDayYear
Date
Return Time*

Hour Minutes

AM/PM Option
Transportation*
Destination*
Purpose of Trip/Activity*
List student(s) involved (alphabetized: Last name, First name)*
Possible Risks - Potential hazards may include but are not limited to the following:*

Cabin use/cooking – burns from woodstove, camp stoves, or cooked food; falling off ladder or bunk; cuts from hatchets,knives, or camping implements, insect bites or stings.City – traffic hazards; separation from group; unwanted approaches from strangersDriving – motor vehicle accidents or injuriesHiking – injuries sustained hiking on uneven and/or unstable ground; falling from heights, footbridges, or tripping; fallingrocks or trees; hostile wildlife, cuts or abrasions from sharp sticks and rocks; hypothermia, dehydration, exhaustionLakes and Rivers – drowning, falling into creeks, injuries from being swept downstream, hypothermia or illness fromcontaminated water, possibly small bruises or blistersWeather – lightning, hail, debris from wind, water, or flooding, warm and cold temperatures, remote chance of mudslidesor avalanchesAthletic Event – broken limbs, concussion, soft tissue injuries, dental injuries, bruisesOther - Note below
Please note other possible risks not mentioned above.
Trip #2 Sponsors/Volunteers*
Departure Date*

MonthDayYear
Date
Departure Time*

Hour Minutes

AM/PM Option
Return Date*

MonthDayYear
Date
Return Time*

Hour Minutes

AM/PM Option
Transportation*
Destination*
Purpose of Trip/Activity*
List student(s) involved (alphabetized: Last name, First name)*
Possible Risks - Potential hazards may include but are not limited to the following:*

Cabin use/cooking – burns from woodstove, camp stoves, or cooked food; falling off ladder or bunk; cuts from hatchets,knives, or camping implements, insect bites or stings.City – traffic hazards; separation from group; unwanted approaches from strangersDriving – motor vehicle accidents or injuriesHiking – injuries sustained hiking on uneven and/or unstable ground; falling from heights, footbridges, or tripping; fallingrocks or trees; hostile wildlife, cuts or abrasions from sharp sticks and rocks; hypothermia, dehydration, exhaustionLakes and Rivers – drowning, falling into creeks, injuries from being swept downstream, hypothermia or illness fromcontaminated water, possibly small bruises or blistersWeather – lightning, hail, debris from wind, water, or flooding, warm and cold temperatures, remote chance of mudslidesor avalanchesAthletic Event – broken limbs, concussion, soft tissue injuries, dental injuries, bruisesOther - Note below
Please note other possible risks not mentioned above.
Trip #3 Sponsors/Volunteers*
Departure Date*

MonthDayYear
Date
Departure Time*

Hour Minutes

AM/PM Option
Return Date*

MonthDayYear
Date
Return Time*

Hour Minutes

AM/PM Option
Transportation*
Destination*
Purpose of Trip/Activity*
List student(s) involved (alphabetized: Last name, First name)*
Possible Risks - Potential hazards may include but are not limited to the following:*

Cabin use/cooking – burns from woodstove, camp stoves, or cooked food; falling off ladder or bunk; cuts from hatchets,knives, or camping implements, insect bites or stings.City – traffic hazards; separation from group; unwanted approaches from strangersDriving – motor vehicle accidents or injuriesHiking – injuries sustained hiking on uneven and/or unstable ground; falling from heights, footbridges, or tripping; fallingrocks or trees; hostile wildlife, cuts or abrasions from sharp sticks and rocks; hypothermia, dehydration, exhaustionLakes and Rivers – drowning, falling into creeks, injuries from being swept downstream, hypothermia or illness fromcontaminated water, possibly small bruises or blistersWeather – lightning, hail, debris from wind, water, or flooding, warm and cold temperatures, remote chance of mudslidesor avalanchesAthletic Event – broken limbs, concussion, soft tissue injuries, dental injuries, bruisesOther - Note below
Please note other possible risks not mentioned above.
Trip #4 Sponsors/Volunteers*
Departure Date*

MonthDayYear
Date
Departure Time*

Hour Minutes

AM/PM Option
Return Date*

MonthDayYear
Date
Return Time*

Hour Minutes

AM/PM Option
Transportation*
Destination*
Purpose of Trip/Activity*
List student(s) involved (alphabetized: Last name, First name)*
Possible Risks - Potential hazards may include but are not limited to the following:*

Cabin use/cooking – burns from woodstove, camp stoves, or cooked food; falling off ladder or bunk; cuts from hatchets,knives, or camping implements, insect bites or stings.City – traffic hazards; separation from group; unwanted approaches from strangersDriving – motor vehicle accidents or injuriesHiking – injuries sustained hiking on uneven and/or unstable ground; falling from heights, footbridges, or tripping; fallingrocks or trees; hostile wildlife, cuts or abrasions from sharp sticks and rocks; hypothermia, dehydration, exhaustionLakes and Rivers – drowning, falling into creeks, injuries from being swept downstream, hypothermia or illness fromcontaminated water, possibly small bruises or blistersWeather – lightning, hail, debris from wind, water, or flooding, warm and cold temperatures, remote chance of mudslidesor avalanchesAthletic Event – broken limbs, concussion, soft tissue injuries, dental injuries, bruisesOther - Note below
Please note other possible risks not mentioned above.
Trip #5 Sponsors/Volunteers*
Departure Date*

MonthDayYear
Date
Departure Time*

Hour Minutes

AM/PM Option
Return Date*

MonthDayYear
Date
Return Time*

Hour Minutes

AM/PM Option
Transportation*
Destination*
Purpose of Trip/Activity*
List student(s) involved (alphabetized: Last name, First name)*
Possible Risks - Potential hazards may include but are not limited to the following:*

Cabin use/cooking – burns from woodstove, camp stoves, or cooked food; falling off ladder or bunk; cuts from hatchets,knives, or camping implements, insect bites or stings.City – traffic hazards; separation from group; unwanted approaches from strangersDriving – motor vehicle accidents or injuriesHiking – injuries sustained hiking on uneven and/or unstable ground; falling from heights, footbridges, or tripping; fallingrocks or trees; hostile wildlife, cuts or abrasions from sharp sticks and rocks; hypothermia, dehydration, exhaustionLakes and Rivers – drowning, falling into creeks, injuries from being swept downstream, hypothermia or illness fromcontaminated water, possibly small bruises or blistersWeather – lightning, hail, debris from wind, water, or flooding, warm and cold temperatures, remote chance of mudslidesor avalanchesAthletic Event – broken limbs, concussion, soft tissue injuries, dental injuries, bruisesOther - Note below
Please note other possible risks not mentioned above.
Trip #6 Sponsors/Volunteers*
Departure Date*

MonthDayYear
Date
Departure Time*

Hour Minutes

AM/PM Option
Return Date*

MonthDayYear
Date
Return Time*

Hour Minutes

AM/PM Option
Transportation*
Destination*
Purpose of Trip/Activity*
List student(s) involved (alphabetized: Last name, First name)*
Possible Risks - Potential hazards may include but are not limited to the following:*

Cabin use/cooking – burns from woodstove, camp stoves, or cooked food; falling off ladder or bunk; cuts from hatchets,knives, or camping implements, insect bites or stings.City – traffic hazards; separation from group; unwanted approaches from strangersDriving – motor vehicle accidents or injuriesHiking – injuries sustained hiking on uneven and/or unstable ground; falling from heights, footbridges, or tripping; fallingrocks or trees; hostile wildlife, cuts or abrasions from sharp sticks and rocks; hypothermia, dehydration, exhaustionLakes and Rivers – drowning, falling into creeks, injuries from being swept downstream, hypothermia or illness fromcontaminated water, possibly small bruises or blistersWeather – lightning, hail, debris from wind, water, or flooding, warm and cold temperatures, remote chance of mudslidesor avalanchesAthletic Event – broken limbs, concussion, soft tissue injuries, dental injuries, bruisesOther - Note below
Please note other possible risks not mentioned above.
Date of Request*

MonthDayYear
Should be Empty: