Field Trip Cover - Distrito Escolar Unificado de San José

FIELD TRIP
INFORMATION

San Jose Unified
School District
2011/2012 School Year
TO: All Principals
FROM: Rose Bedard, Auxiliary Services
RE: Student Accident Insurance 2011-2012
Refer questions to Chris Hernandez @535-6510
2222 Unified Way ● San Jose, California 95125 ● (408) 535-6510● Fax (408) 297-9849
06/09/2011 RB:ch
AUXILIARY SERVICES
RISK MANAGEMENT DEPARTMENT
“Inspiring and Preparing for Success”
For the upcoming school year, the District will be making student accident
insurance available to parents (for voluntary purchase through Myers-Stevens &
Toohey & Co., Inc.). Materials relating to this program will be shipped to your
school prior to the resumption of classes and should be sent home to the
parents of every enrolled student. (Note: student insurance forms relating to
last yearʼs program should be discarded).
The shipment will include a flyer entitled INSTRUCTIONS FOR SCHOOL
PERSONNEL. A copy of these instructions should be given to those members
of your staff (athletic/activities directors, school nurses, coaches, etc.) whose
responsibilities include the verification of insurance for students. Of particular
importance are the sections dealing with “Enrollment Procedures” and “Effective
Date of Coverage.”
If students choose to enroll in the program, they mail the completed
brochures directly to Myers-Stevens & Toohey & Co., Inc. You do not
have to do anything with the forms, as it is the familyʼs responsibility.
PLEASE NOTE: School related injuries to uninsured students might cause
financial hardship for parents and additional liability exposure and expense to
the District. Your assistance with ensuring that all students are given the
opportunity to enroll will benefit parents and the District.
Thank you for your cooperation. Questions regarding the student insurance
program may be directed to Myers-Stevens & Toohey & Co., Inc. at 1-800-827-
4695.

San Jose Unified
School District
2011/2012 School Year
To: All Principals
From: Rose Bedard
Re: Insurance for School Sponsored Field Trips
2222 Unified Way ● San Jose, California 95125● (408) 535-6510 ● Fax (408) 297-9849
06/09/2011 RB:ch
AUXILIARY SERVICES
RISK MANAGEMENT DEPARTMENT
“Inspiring and Preparing for Success”
The Governing Board recognizes that school sponsored trips are important components of a student’s
development.
The California Education Code requires that all students must have insurance in order to go on field
trips. San Jose Unified provides this coverage on all one day field trips when there is direct and
immediate supervision by school personnel.
All other field trips must have additional insurance purchased through the Risk Management
Department prior to the field trip. The short term (24 hour) coverage provides excess accident and
acute illness medical coverage and accidental death and dismemberment coverage for students
participating in school sponsored and supervised activities involving overnight travel, activities that are
beyond the 100 mile radius requirement, activities that involve water or amusement parks and
activities that are out of state or out of country. There is a small rate for this coverage. Coverage
consists of basic and catastrophic benefits. Myers-Stevens & Toohey Co., Inc. provide this coverage
for San Jose Unified.

San Jose Unified
School District
2222 Unified Way ● San Jose, California 95125 ● (408) 535-4727 ● Fax (408) 297-9849
AUXILIARY SERVICES
RISK MANAGEMENT DEPARTMENT
“Inspiring and Preparing for Success”
Ms. Rose Bedard 2011/2012
Director, Auxiliary Services
Dear Parent:
San Jose Unified School District does not provide medical insurance coverage for school accidents.
This means that you are responsible for the medical bills if your child gets hurt during school activities.
The accompanying student accident/health insurance plans are offered to help you pay those bills.
Many coverage options are available. The Student Health Care and High Option Full Time
(24 Hour) Accident plans are especially recommended for those students with no other insurance
because they provide the most help when injuries occur. Student Health Care covers illness as well as
injury, 24 hours a day. We strongly recommend the high option plan for students participating in
interscholastic sports.
If your child does have other health coverage, student insurance may also be used to help pay those
eligible charges not covered by other insurance (i.e. deductibles and co-payments). While you can
always use any doctor or hospital, the Student Health Care plan includes access to an extensive
network of doctors and hospitals that have agreed to discount their charges. To find the contracted
medical providers nearest you, call 1-800-877-1666 or log on to www.beechstreet.com.
Please read your brochure carefully. If you enroll in the plan, mail your check and form directly to
Myers-Stevens. Do not turn paperwork into your child’s school. If you have any questions, please call
the plan administrator, Myers-Stevens & Toohey & Co., Inc. at 1-800-827-4695 or 1-949-348-0656.
Bilingual representatives are available for parents who need assistance in Spanish.
In order to document your having been notified of this matter, please sign and complete the
bottom of this form and immediately send it back to the school with your child.
Sincerely,
Rose Bedard
Director, Auxiliary Services
SCHOOL NAME:
As parent/guardian of, I understand that SJUSD does not provide medical insurance for student injuries
but does make voluntary student insurance available. I have received the information on this program.
I will enroll my child in the program. I will not enroll my child in the program.
Signed Date

02/24/2012 RB:ch
San Jose Unified School District
Volunteer Driver Guidelines
1. Complete the Driver Information Form. You must show proof of auto insurance
that meets state legal requirements, car registration, and driverʼs license and
be 21 years of age or older.
5
2. Your car is in safe condition with good brakes and tires (including the spare); you
have enough gasoline.
3. Arrive at the departure point early enough to allow plenty of time for loading
students and receiving instructions.
4. The teacher will provide you with:
• Appropriate permission/ medical release forms for students. In case of an
accident, these are necessary to insure prompt treatment.
• The school phone number and emergency contact person.
• Directions/Map to destination. Be sure you know exactly where you are going.
This includes rest/refreshment stops. All stops must be approved.
5. Before leaving, review or explain safety rules:
• A car seat or booster is required in the back seat for children under the age of
8. However, children under the age of 8 who are 4ʼ9” or taller may be secured
by a safety belt in the back seat.
• If front air bags, children 12 and under or 4ʼ9” and under are seated in back
seat.
• Seat Belts on at all times.
• Hands and arms inside.
• Noise must be kept to a level acceptable to driver.
• Special rules for your car.
6. Observe speed limits and abide by all laws and regulations.
7. Alcohol shall not be used at any school function, whether on school property or
elsewhere, when persons under 21 are present. Illegal substance shall not be
used at any school function whether on school property or elsewhere.
8. Smoking in the vehicle is prohibited. The use of tobacco products will not be
permitted at any SJUSD function except by adults in designated areas.
Designated areas will be away from nonusers.
9. If an injury requiring treatment occurs, health history records and permission slips
should accompany a child or an adult to the doctor or hospital.
10. The student supervision ratio will be observed at all times while on the trip. At
least one adult per five students, grades K-2 and one adult per ten students,
grades 3-12, with a minimum of two adults are required for continuous monitoring
of students.
11. When the trip is over, return permission/medical release forms to the leader.
NOTE: Driver should keep guidelines and return the Driver Information form
and Notice of Liability To Volunteer Driver form to the School Office.

02/27/2012 RB:ch
SAN JOSE UNIFIED SCHOOL DISTRICT
FIELD TRIP PROCESSING
CHECK OFF LIST
SUPERVISOR/TEACHER
____ BOARD AGENDA
____ PERMISSION SLIP
____ GUIDELINES FOR FIELD TRIP SIGNED OFF
____ BOARD POLICY READ AND UNDERSTOOD
(SIGNED OFF)
____ TRIP PLANS IN OFFICE
____ LUNCHES ORDERED
____ WAIVER (WHEN APPLICABLE)
OUT OF STATE OR OVERNIGHT TRIPS
UNSUPERVISED OR NON-SCHOOL HOUR TRIP
____ ADDITIONAL INSURANCE (WHEN APPLICABLE)
OUT OF STATE OR OVERNIGHT TRIPS
UNSUPERVISED OR NON-SCHOOL HOUR TRIP
____ STAFF VOLUNTEER DRIVER FORM WITH DRIVER’S LICENSE,
INSURANCE AND REGISTRATION ATTACHED IF DRIVING
____ RATIO FOR FIELD TRIP SUPERVISION
(Must be 1 to 5 for grades K-2 and 1 to 10 for 3-12).
STUDENT ROSTER OR PERMISSION SLIPS ON FILE WITH SITE
PARENT/PARENT VOLUNTEER
STUDENT
____ VOLUNTEER DRIVE FORM FILLED OUT IF DRIVING
____ COPY OF DRIVER’S LICENSE, REGISTRATION AND
INSURANCE FOR VOLUNTEER DRIVERS
____ COPY OF PERMISSION SLIPS / MEDICAL FORMS
____ A CAR SEAT OR BOOSTER IS REQUIRED IN THE BACK SEAT
FOR CHILDREN UNDER THE AGE OF 8. HOWEVER,
CHILDREN UNDER THE AGE OF 8 WHO ARE 4’9” OR TALLER
MAY BE SECURED BY A SAFETY BELT IN THE BACK SEAT
____ SEAT BELTS FOR ALL PASSENGERS
____ FIRST AIDE KIT
____ CELL PHONE
____ TURNED IN SIGNED PERMISSION SLIP AND
MEDICAL FORM

San Jose Unified
School District
Rose Bedard
Director, Auxiliary Services DRIVER INFORMATION FORM
Dear Volunteer Driver:
AUXILIARY SERVICES
RISK MANAGEMENT DEPARTMENT
REVISED 1/1/12 2222 Unified Way, Bld. T ● San José, California 95125 ● (408) 535-6510 ● Fax (408) 297-9849
“Inspiring and Preparing for Success”
Thank you for volunteering to serve as a driver for transporting students on field trips. By so volunteering, you will be
assuming certain responsibilities and possible risks. On the form, we have outlined District policy regarding volunteer
drivers. The policy was developed with the idea of providing the safest alternative possible when District busses are not
available for field trips. The student supervision ratio must be observed at all times 1 to 5 for K-2 and 1 to 10 for 3-12).
The adopted policy request 1) that we have on file certain information about you and your insurance and 2) that volunteer
drivers understand and agree to the requirements listed below and on the reverse:
1. An application form must be completed for each trip and be on file with the School Office two days prior to the trip.
2. A signed Notice of Liability to Volunteer Driver form must be filed in the school office prior to the trip. (Reverse side
of form).
3. Limit of not less than $100,000 each person, $300,000 each occurrence for bodily injury and $25,000 property
damage coverage must be carried by driver. A copy of the declaration page to the insurance policy must be attached.
4. A copy of your car registration and driver’s license must be attached.
5. The number of passengers per vehicle shall not exceed one per passenger seat belt provided.
6. Each passenger shall have a seat belt available and must wear it.
7. A car seat or booster is required in the back seat for children under the age of 8. However, children
under the age of 8 who are 4’9” or taller may be secured by a safety belt in the back seat.
8. If a car has front air bags, children 12 and under or 4’9” and under must be seated in the back seat.
9. Driver will carry a cell phone and a First Aid Kit in case of emergencies.
10. All volunteer drivers must be at least 21 years of age.
11. The distance traveled shall not exceed 120 miles, one way.
12. The trip shall be limited to travel within the State of California.
13. The trip shall begin and be completed the same day. No unauthorized stops are permitted.
14. All applicable laws must be obeyed.
15. Read and follow Volunteer Driver’s Guidelines (please initial)
Please complete the blanks below and return the form to the school office.
1. Name of Driver ____
2. Make and Model of Car ____ License Plate #
3. Number of passengers/seat belts your automobile is designed to carry (in addition to the driver) ______
4. Cell Phone # Home Phone #
The Following Documents must be attached:
1. Driver’s License 2. Insurance policy declaration page 3. Copy of car registration
I hereby offer to provide for the transportation of students of the San Jose Unified School District. In making this offer, I understand
in the event of a vehicular accident, coverage is provided by the volunteer driver’s own automobile insurance. The school system does
not provide insurance coverage should a vehicular accident occur while a volunteer driver is transporting students. Thank you for your
cooperation and assistance.
Teacher Principal Date
Volunteer Driver Date

San Jose Unified
School District
NOTICE TO VOLUNTEER DRIVERS
(Aged 21 or over)
AUXILIARY SERVICES
RISK MANAGEMENT DEPARTMENT
REVISED 1/1/12 2222 Unified Way, Bld. T ● San José, California 95125 ● (408) 535-6510 ● Fax (408) 297-9849
“Inspiring and Preparing for Success”
I, the undersigned, as a volunteer driver, understand that by using my automobile for transporting students on
field trips. I am exposing myself to liability for injury to passengers in my car. I realize there is a possibility of
an accident occurring, and in the event of injury to any of the occupants of my car, I understand that I, and/or
my insurance company may be liable. I understand also that the San Jose Unified School District does not
provide insurance coverage for volunteer drivers either in place of, or supplementary to my personal automobile
liability insurance or any physical damage that could occur to my vehicle (School District) insurance protects
the District only in the event it should be named as a defendant.
Date Signature of Driver
__________________________________
City Where Signed
If you have questions regarding this procedure, please discuss them with your principal or Risk Management
at 535-6510.
Please return this form to the school office before driving as a volunteer.
Note: Completed forms are filed in the school office.

Sra. Rose Bedard
San Jose Unified
School District
Directora de Servicios Auxiliares
Estimado conductor voluntario:
FORMULARIO DE INFORMACIÓN PARA CONDUCTORES
AUXILIARY SERVICES
RISK MANAGEMENT DEPARTMENT
REVISED 1/1/12 2222 Unified Way, Bld. T ● San José, California 95125 ● (408) 535-6510 ● Fax (408) 297-9849
“Inspiring and Preparing for Success”
Gracias por ofrecerse como conductor voluntario para transportar a los estudiantes en excursiones. Al ser voluntario, usted asumirá
ciertas responsabilidades y posibles riesgos. En el formulario, hemos destacado la política del Distrito con respecto a los conductores
voluntarios. Dicha política se elaboró con la idea de proporcionar la alternativa más segura posible cuando los autobuses del Distrito no
están disponibles para excursiones. Los requisitos de supervisión de los estudiantes deben respetarse en todo momento; teniendo a 1
adulto por cada 5 estudiantes en los grados Kinder a 2º y a 1 adulto por cada 10 estudiantes en los grados 3º al 12º. La política
adoptada solicita que 1) tengamos en nuestros archivos cierta información acerca de usted y su seguro y 2) que los conductores
voluntarios entiendan y estén de acuerdo con los requisitos que se indican abajo y al reverso:
1. Se debe llenar un formulario de solicitud por cada viaje y entregarse a la oficina de la escuela por lo menos dos días antes del
viaje.
2. Se debe firmar el formulario de Aviso de Responsabilidad del Conductor Voluntario en la oficina de la escuela antes del viaje.
(reverso del formulario)
3. El conductor deberá tener un límite de cobertura de seguro automovilístico de no menos de $100,000 por cada persona,
$300,000 en cada caso de daño corporal y $25,000 por daño de propiedad. Deberá incluirse una copia de la página de
declaración de la póliza de seguro.
4. Se deberá incluir una copia del registro del automóvil y de la licencia de manejar del conductor.
5. El número de pasajeros por vehículo deberá ser el mismo que los cinturones de seguridad que tenga el vehículo.
6. Cada pasajero deberá tener un cinturón de seguridad disponible y deberá usarlo.
7. Se requiere usar un asiento de seguridad infantil en el asiento trasero del automóvil para los niños menores de 8 años. Sin
embargo, los niños menores de 8 años que midan 4 pies y 9 pulgadas de estatura o sean más altos pueden ir sentados en el
asiento trasero del vehículo con su cinturón de seguridad puesto.
8. Si el vehículo tiene bolsas de aire al frente, los niños de 12 años de edad o que midan 4 pies y 9 pulgadas de estatura o sean
más bajos deben sentarse en el asiento trasero del vehículo.
9. El conductor debe llevar un teléfono celular y un estuche de primeros auxilios en caso de emergencia.
10. Todos los conductores voluntarios deben tener por lo menos 21 años de edad.
11. La trayectoria del viaje no deberá exceder120 millas, en un solo sentido.
12. El viaje deberá ocurrir dentro de los límites del estado de California.
13. El viaje deberá empezar y terminar el mismo día. No se permitirá ninguna parada sin autorización.
14. Todas las leyes aplicables deben seguirse al pie de la letra.
15. Leer y seguir la Guía de los Conductores Voluntarios.________(por favor escriba sus iniciales)
Por favor complete los siguientes espacios en blanco y entregue este formulario a la oficina de la escuela de su hija/hijo.
1. Nombre del conductor(a)___________________________________
2. Marca y modelo del carro__________________________________Número de la placa __________________
3. Número de pasajeros/cinturones de seguridad para los que está diseñado su carro (además del conductor) _______
4. Número de teléfono celular ____________________ Número de teléfono de su hogar_________________________
Los siguientes documentos deben incluirse con este formulario:
1. Licencia de manejo 2. Página de declaración de la póliza de seguro 3. Copia del registro de su automóvil
Por medio de la presente ofrezco proporcionar transporte a los estudiantes del Distrito Escolar Unificado de San José. Al hacerlo, entiendo que en caso
de que ocurriera un accidente vehicular, el seguro de automóvil del conductor voluntario proporcionará cobertura. El sistema escolar no proporciona
cobertura de protección de seguro en caso de que ocurriera un accidente vehicular mientras el conductor voluntario esté transportando estudiantes.
Muchas gracias por su cooperación y ayuda.
Maestra(o) __________________________________ Director(a) ______________________________ Fecha _____________
Conductor(a) voluntario(a) _____________________________________________________________ Fecha _____________

San Jose Unified
School District
AVISO PARA LOS CONDUCTORES VOLUNTARIOS
(de 21 años de edad y mayores)
AUXILIARY SERVICES
RISK MANAGEMENT DEPARTMENT
REVISED 1/1/12 2222 Unified Way, Bld. T ● San José, California 95125 ● (408) 535-6510 ● Fax (408) 297-9849
“Inspiring and Preparing for Success”
Yo, la persona que firma al calce de este documento, como conductor o conductora voluntario(a),
entiendo que al usar mi automóvil para transportar estudiantes durante excursiones o viajes de
estudio, me expongo a que se me responsabilice de las lesiones que pudieran ocurrirles a los
pasajeros que viajen conmigo en mi vehículo. Me doy cuenta de que existe la posibilidad de que
ocurra un accidente, y que en caso de que algún ocupante de mi vehículo resultara lesionado,
entiendo que se me podrá responsabilizar a mí o a mi compañía de seguro de automóvil.
También entiendo que el Distrito Escolar Unificado de San José no proporciona cobertura de
seguro de automóvil para los conductores voluntarios ya sea en lugar de, o suplementaria a mi
seguro personal de automóvil, ni tampoco por cualquier daño físico que pudiera ocurrirle a mi
vehículo. El seguro (del Distrito Escolar) protege al Distrito únicamente en caso de que se le
nombre como acusado en un litigio.
Fecha Firma del conductor(a)
__________________________________
Ciudad donde se firmó este documento
Si tiene preguntas con respecto a este procedimiento, por favor hable con el director de su
escuela o con la Oficina de Administración de Riesgos al 535-6510.
Por favor regrese esta forma a la oficina de la escuela antes de conducir como voluntario.
Nota: Los formularios completos se presentan en la oficina de la escuela.

San Jose Unified
School District
Rose Bedard
Director, Auxiliary Services STAFF DRIVER INFORMATION FORM
Dear San Jose Unified School District Staff Volunteer Driver:
2222 Unified Way ● San Jose, California 95125 ● (408) 535-4727 ● Fax (408) 297-9849
AUXILIARY SERVICES
RISK MANAGEMENT DEPARTMENT
“Inspiring and Preparing for Success”
Thank you for volunteering to serve as a driver for transporting students on field trips. By so volunteering, you will be
assuming certain responsibilities and possible risks. On the form, we have outlined District policy regarding volunteer
drivers. The policy was developed with the idea of providing the safest alternative possible when District busses are not
available for field trips. The student supervision ratio must be observed at all times 1 to 5 for K-2 and 1 to 10 for 3-12). The
adopted policy request 1) that we have on file certain information about you and your insurance and 2) that volunteer
drivers understand and agree to the requirements listed below and on the reverse:
1. An application form must be completed for each trip and be on file with the School Office two days prior to the trip.
2. A signed Notice of Liability to Volunteer Driver form must be filed in the school office prior to the trip.
3. Limit of not less than $100,000 each person, $300,000 each occurrence for bodily injury and $25,000 property
damage coverage must be carried by driver. A copy of the declaration page to the insurance policy must be attached.
4. The number of passengers per vehicle shall not exceed one per passenger seat belt provided.
5. Each passenger shall have a seat belt available and must wear it.
6. A car seat or booster is required until the passenger is at least 6 years of age or 60 pounds.
7. If a car has front air bags, children 12 and under or 4’9” and under must be seated in the back seat.
8. Driver will carry a cell phone and a First Aid Kit in case of emergencies.
9. All volunteer drivers must be at least 21 years of age.
10. The distance traveled shall not exceed 120 miles, one way.
11. The trip shall be limited to travel within the State of California.
12. The trip shall begin and be completed the same day. No unauthorized stops are permitted.
13. All applicable laws must be obeyed.
15. Read and follow Volunteer Driver’s Guidelines _________ (please initial).
15. Read and understand the Board Policy_________ (please initial).
Please complete the blanks below and return the form to the school office.
1. Name of Driver ________________________________________________
2. Name of Insurance Company _____________________________________
3. Name of insured as shown on the policy _____________________________
4. Policy Number ________________________ Expiration Date____________
5. Insurance Coverage: Liability Limits ________________________________
6. Your Driver’s License Number ____________ Expiration Date ________(Attached copy of driver’s license)
7. Make and Model of Car ________________________ License Plate #________
8. Number of passengers/seat belts your automobile is designed to carry (in addition to the
driver) ____________Cell Phone # _____________________________________
I hereby offer to provide for the transportation of students of the San Jose Unified School District. In making this offer, I
understand in the event of a vehicular accident, coverage is provided by the volunteer driver’s own automobile insurance.
The school system does not provide insurance coverage should a vehicular accident occur while a volunteer driver is
transporting students. Thank you for your cooperation and assistance.
Employee’s Name____________________________________ Supervisor _________________________________
Date ____________________________________________

Instruction
E (2) 6153(a)
SAN JOSE UNIFIED SCHOOL DISTRICT
APPROVAL REQUEST FOR ALL STUDENT FIELD TRIPS, GRADES K-12
Guidelines/Requirements for Approval
Trips Requiring Principal's Approval Only: All trips taken within Santa Clara County. Please
submit this form prior to departure to the principal for approval.
Trips Requiring Approval by the Principal and Director, Educational Services: All trips
taken beyond Santa Clara County and within a 100 mile radius of the school. Please submit this
form to the principal two weeks prior to departure. If approved, please forward it to the district
office.
Trips Requiring Principal, Director, Educational Services and Governing Board Approval:
All trips taken beyond a 100 mile radius of the school, and/or where students stay overnight
(regardless of distance), and/or where students will miss more than one day of instruction.
Please submit this form to the principal six weeks prior to departure. Trips requiring fundraising
of $5000 or more must have Board approval four months prior to the activity.
General Information
Date of this request_____________________ School_____________________
Name of Group/Organization_____________________________________________
Teachers/Administrators Responsible for this trip_____________________________
Trip's Specific Destination _____________________________________________
Trip Date(s)___________________________________________________________
Time of Departure _______________ Time of Return_______________________
The purpose of the trip is: _____________________________________________
TRANSPORTATION INFORMATION
Method of Transportation (check appropriate space):
Private Vehicle ________ Bus _________ No. of Buses to be used:______________
No. of Private Vehicles:______________ Train ____________ Airplane ___________

E (2) 6153(b)
If you are using a private vehicle, please place a check next to each space indicating that each
requirement has been met.
1. Seat belts are available for each passenger.
2. Signed Volunteer Driver Form is on file in the school office.
3. $100,000/$300,000 public liability and $25,000 property damage coverage is in effect and
carried by the driver. Principal or designee has verified insurance if current.
Student Supervision and Fundraising Information
Grade Level of Students on the Trip ______________________________________
No. of Student Participants on the Trip _____________________________________
No. of Adult Supervisors on this Trip _____________________________________
(At least one adult per five students, grades K-2, and one adult per ten students, grades 3-12,
with a minimum of two adults is required for continuous monitoring of students.)
Parent Permission Slips for each student are on file in the school's office:
Yes ______________ No __________________
How were the students selected for this trip? _______________________________
The source of funding for this trip is:_______________________________________
Will every student participating on the trip be able to attend regardless of his/her ability to pay?
___________________________________________________________________________
If students are paying individually, how many scholarships are offered? __________

Approvals
E (2) 61653(c)
Please submit this form to your school's principal for approval. If necessary, the school principal
will send it to the Director, Educational Services for district administration approval. Trips
requiring Board approval will be submitted on the regular Board meeting agenda prior to the trip
taking place.
Approved: ______________________ Date:________________________________
Principal
(If necessary) Approved: __________________________ Date:_______________
Director, Educational Services
(If necessary) Approved by the Governing Board on:______________________________

PLEASE COMPLETE BOTH SIDES OF THIS FORM AND RETURN TO YOUR CHILD’S TEACHER
AS SOON AS POSSIBLE
Dear Parent:
SAN JOSE UNIFIED SCHOOL DISTRICT
PARENT-PUPIL PERMISSION SLIP FOR FIELD TRIPS
___________________________________________________is taking the class on a study trip
(teacher)
to _____________________________on ________________ from _________ to____________.
(place/location) (day/date) (time).
Method of transportation will be:
____walking ____light rail ____public transportation
____private car ____school bus
Please indicate your approval for your child to go on this trip by signing in the space provided below and complete the
emergency phone number and chaperone sections. Thank you.
_____________________________________
Principal
I give permission for_________________________________________________to go on the study trip.
(Student’s name)
Parent signature/date _______________________________________________
Emergency phone numbers:
____________________________________ _______________________________________
(name/phone number) name/phone number)
____ Yes, I would like to chaperone. _____ No, I do not have a driver’s form and
____ Yes, I can drive, if necessary and would like one sent to me.
have a driver’s form on file in the
office.
**************************************************************************************************************************************
FIELD TRIP LUNCHES SIGN UP SHEET
Your child will be going on a field trip during school hours. The cafeteria will be offering bag lunches to all the students on
the field trip. The bag lunch will include a sandwich, condiments, fresh fruit, vegetable sticks, a bag of chips or crackers,
and juice. The lunch will cost $2.75/Elementary or $3.25/Secondary or, no charge for those eligible for free meals, $.40 for
children eligible for reduced priced meals. Please indicate below if your child will need to purchase a bag lunch for the trip,
or if he/she will be bringing along a lunch from home. Please notify us of any food allergies so we may
plan accordingly.
Child’s Name ___________________________________________________________
_____ Yes, I would like to order a bag lunch for the field trip on ______________________.
_____ No, my child will bring a lunch from home for the field trip.
_______________________________________________________________
(Parent signature)
*Please copy before tearing off. Medical information form on back. 12/14/10 RB:ch

POR FAVOR LLENE AMBOS LADOS DE ESTE FORMULARIO Y DEVUÉLVALO A LA MAESTRA O
MAESTRO DE SU HIJO(A), LO MÁS PRONTO POSIBLE
Estimados padres:
DISTRITO ESCOLAR UNIFICADO DE SAN JOSÉ
FORMULARIO DE PERMISO PADRES-ALUMNO PARA EXCURSIONES
______________________________________________llevará a su clase a un viaje de estudio
(maestra/maestro)
a _____________________________el ________________ de _________a____________.
(lugar) (día/fecha) (hora)
El método de transporte será:
____caminando ____tranvía ____transporte público
____carro particular ____autobús escolar
Por favor indique su aprobación para que su hijo(a) vaya a este viaje de estudio, firmando el espacio apropiado abajo y
complete las secciones de teléfono de emergencia y acompañantes. Gracias.
_____________________________________
Directora/Director
Yo le doy permiso a____________________________________para que vaya al viaje de estudio.
(Nombre del estudiante)
Firma de madre, padre o tutor/fecha ____________________________________________
Números de teléfono de emergencia:
____________________________________ _______________________________________
(nombre/num.de teléfono) (nombre/num.de teléfono)
____ Sí, yo deseo ir como acompañante. _____ No, no tengo un formulario del conductor
y deseo que me envíen uno.
____ Sí, yo puedo conducir, si es necesario
y en la oficina de la escuela tienen
mi formulario del conductor firmado y archivado.
*****************************************************************************************************************************************
HOJA PARA FIRMAR PARA OBTENER ALMUERZOS EN LAS EXCURSIONES
Su hijo(a) irá a una excursión durante el horario escolar. La cafetería ofrecerá almuerzos en bolsita para todos los
estudiantes durante la excursión. La bolsita de almuerzo incluirá un sandwich, condimentos, fruta fresca, tiras de
verduras, una bolsita de papas fritas o de galletas saladas y un jugo. El costo del almuerzo será de $2.75/Primaria o
$3.25/Secundaria y Preparatoria o gratis para los estudiantes que cumplan los criterios para recibir alimentos sin costo
alguno y 40¢ para los estudiantes que cumplen los criterios para recibir alimentos a precio de descuento. Por favor
indique abajo si su hijo(a) necesitará comprar un almuerzo en bolsita para el viaje de estudios, o si él/ella traerá su propio
almuerzo de casa. Por favor infórmenos sobre cualquier alergia a alimentos que padezca su niño/niña para que
podamos planear adecuadamente.
Nombre del niño/niña: ___________________________________________________________
_____ Sí, yo deseo ordenar un almuerzo en bolsita para la excursión del ______________________.
_____ No, mi hijo/hija llevará su propio almuerzo de casa para la excursión.
_______________________________________________________________
(Firma de madre, padre o tutor legal del estudiante)
* Por favor copie antes de recortar. Formulario de información médica al reverso. 12/14/10 RB:ch

SAN JOSE UNIFIED SCHOOL DISTRICT MEDICAL FORM
Trip Date(s)
Supervisor
Participant’s Name Age
Telephone Contact Information
Home Cell Work
Please answer YES or NO to each question listed below. Every question must be answered before
attending the trip. A YES does not automatically disqualify participants from attending the trip. The
information is simply to provide the guide(s) and Outdoor Activities Director an assessment of each
participant’s medical history before heading into the fields. This information is confidential.
1. Respiratory problems? Asthma YES NO 6. Neurological problems? Epilepsy? YES NO
If yes, do they carry an inhaler? YES NO Migraines? YES NO
2.Diabetes YES NO 7. Cardiac problems? If Yes, please list YES NO
If yes, do they use insulin? YES NO in space provided.
3.Any hip,ankle,shoulder,arm or YES NO 8. Any allergies? If yes, pleases specify. YES NO
back injuries/operations? If yes,
state body part & list date of
injury.
4. Allergic to insect bites or bee YES NO 9. Food allergies? Dietary restrictions? YES NO
stings? If yes, do they carry an YES NO Vegan,Vegetarian? Please specify.
epinephrine pen?
5. Do they take any medications? YES NO List medications & symptoms here.
If yes, please list medications.
Medication Dosage(Amt./Freq.) Side effects/Restrictions
Swimming Ability (If applicable) Non-Swimmer Recreational Competitive
Please list any medical or physical problems that are not covered in the above listed questions that may
affect participation in a class trip. Write N/A if not applicable.
EMERGENCY CONTACT INFORMATION
Name: Name:
Relationship: Relationship:
Phone: Phone:
Parent/guardian of the child listed above, give permission for any adult/employee/volunteer of San Jose
Unified School District in whose care said minor child has been entrusted, to seek emergency medical
care for my child at a nearby hospital or medical clinic in the event of illness or injury. I, the
parent/guardian, will assume any and all financial responsibility for such emergency medical care.
Print Name(Guardian) Sign Name(Guardian) Date Revised 3/07RB:bb

FORMULARIO DE INFORMACIÓN MÉDICA DEL DISTRITO ESCOLAR UNIFICADO DE SAN JOSÉ
Excursión Fecha(s)
Supervisor(a)
Nombre del participante Edad
Información de contacto telefónico:
Casa Celular Trabajo
Por favor conteste SÍ o NO a cada una de las siguientes preguntas. Cada pregunta debe contestarse antes de poder asistir a la
excursión. Contestar SÍ no descalifica automáticamente a los participantes para que asistan a una excursión. Esta información es
simplemente para proporcionarle a los guías y al Director de Actividades al aire libre una evaluación del historial médico de cada
participante antes de dirigirse a los campos. Toda la información que usted proporcione es confidencial.
1. ¿Problemas respiratorios? Asma SÍ NO 6. ¿Problemas neurológicos? ¿Epilepsia? SÍ NO
Si SÍ, ¿lleva consigo un inhalador? SÍ NO ¿Migrañas? SÍ NO
2.¿Diabetes? SÍ NO 7. ¿Problemas cardiacos? SÍ NO
Si SÍ, ¿usa insulina? SÍ NO Si SÍ, por favor escríbalos en el espacio proporcionado
3. ¿Alguna lesión/operación de la
cadera, tobillo, hombro, brazo o
espalda? Si SÍ, escriba la parte del SÍ NO 8. ¿Alguna alergia? Si SÍ, por favor especifíquela
cuerpo y la fecha de la lesión u
operación.
4. ¿Alergias a piquetes de insectos SÍ NO 9. ¿Alergias a alimentos? ¿Restricciones en la dieta? SÍ NO
o de abeja? Si SÍ, ¿lleva consigo una SÍ NO ¿Vegano,vegetariano? Por favor especifique.
pluma o inyección de epinefrina?
5. ¿Toma alguna medicina? SÍ NO Escriba aquí las medicinas que toma y los síntomas del
Si SÍ, por favor escriba sus nombres. participante.
Medicamento(s) Dosis(Cantidad/Frecuencia) Efectos secundarios/Restricciones
Habilidad para nadar (si es aplicable):
No sabe nadar Nadador(a) casual Nadador(a) de competencias
Por favor escriba cualquier problema médico o físico que no se haya mencionado en las preguntas de arriba y que podría afectar
la participación de su hijo/hija en una excursión o viaje de estudios de su clase. Escriba las letras N/A si ésto no es aplicable.
INFORMACIÓN DE CONTACTOS EN CASO DE EMERGENCIA
Nombre: Nombre:
Relación: Relación:
Teléfono: Teléfono:
Yo, el padre, madre o tutor del estudiante mencionado arriba, otorgo mi permiso para que cualquier adulto/empleado/voluntario
del Distrito Escolar Unificado de San José, en cuya custodia he depositado el cuidado de mi hijo/hija, busque atención médica de
emergencia para mi hija/hijo mencionado arriba en un hospital o clínica médica cercana, en caso de que ocurriera una
enfermedad o lesión. Yo, en mi papel de padre, madre o tutor, asumiré cualquiera y toda responsabilidad financiera que surja
como consecuencia de tal atención médica de emergencia en caso de que la hubiere.
Nombre con letra clara (del padre, madre o tutor) Firma (del padre, madre o tutor) Fecha
Revised 3/07RB:bb Spa/mdm

Name of Student or Volunteer:
San Jose Unified School District
WAIVER, RELEASE, and INDEMNITY
School: Faculty Sponsor:
Date/Time of departure: Date/Time of Return:
Itinerary/Destination/nature of activity:
I understand that there are risks and dangers inherent in participating in outdoor activities. I also understand that in order to
be allowed to participate in this activity, I must give up my rights to hold the San Jose Unified School District, its Trustees,
employees, and volunteers liable for any injury or damage which I may suffer while participating in this activity. Knowing this and in
consideration of being permitted to participate in this activity, I hereby voluntarily release the San Jose Unified School District, its
Trustees, employees, and volunteers from any and all liability resulting from or arising out of my participation in this activity.
I understand and agree that this Agreement will have the effect of releasing, discharging, waiving, and forever relinquishing
any and all actions or causes of action that I may have or have had, whether past, present, or future, whether known or unknown, and
whether anticipated or unanticipated by me, arising out of my participation in this activity. This Release constitutes a complete
release, discharge and waiver of any and all actions or causes of action against the San Jose Unified School District, its Trustees,
employees, and volunteers.
I understand and agree that this Agreement applies to personal injury, property damage, or wrongful death, which I may
suffer, even if caused by the negligent acts or omissions of others. I understand and agree that by signing this Agreement, I am
assuming full responsibility for any and all risk of death or personal injury or property damage which I may suffer while participating
in this activity. I understand and agree that by signing this Agreement, I am agreeing to release, indemnify, and hold the San Jose
Unified School District, its Trustees, employees, and volunteers harmless from any and all liability or costs, including attorney’s fees,
associated with or arising from my participation in this activity.
I hereby release San Jose Unified School District, its officers, agents or employees, to arrange for my medical treatment, if
necessary, at my expense. In the event I am unable to give instructions for medical care, full authorization is given to any licensed
physician and/or surgeon to whom I am taken, to treat, administer drugs and medication, and perform surgical treatment, as he or she
shall think the existing emergency requires, for the relief of pain and/or the preservation of life and/or health and well-being. I
understand that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required; instead it is
given to provide the authority and power to the San Jose Unified School District to be in a position to make necessary arrangements
for attempting to secure reasonable care under emergency circumstances. Any costs incurred in this connection not covered by my
insurance shall be paid by me.
I understand and agree that this Agreement will be binding on me, my parents and siblings, spouse, my heirs, my personal
representatives, my assigns, my children, and any guardian ad litem for said children. I understand and agree that if I am signing this
Agreement on behalf of my minor child, that I will be giving up the same rights for said minor as I would be giving up if I signed this
document on my own behalf.
I acknowledge that I have read this Agreement and that I understand the words and language in it. I have been advised of the
potential dangers incidental to participating in this activity.
Statement of Good Health: Participant, or their parent/guardian, represents that s/he is in good physical condition to engage
in this activity. If said physical condition changes, participant will voluntarily withdraw from the activity.
Each participant is hereby advised to consult a physician prior to enrolling in a strenuous physical activity.
PARENT/GUARDIAN RELEASE:
I am the parent/legal guardian of the minor, and I am signing this document on behalf of said minor.
Print Name of Parent/Guardian: Signature of Parent/Guardian:
VOLUNTEER RELEASE: I am a volunteer, 18 years of age or older, and I am signing this document on my own behalf.
Print Name: Signature:
ADULT STUDENT RELEASE:
I, am a student 18 years of age or older and I am signing this document on my own behalf.
Print Name
Signature of Adult Student: Date
12/14/10 RB:ch
Date
Date

Distrito Escolar Unificado de San José
RENUNCIA, LIBERACIÓN e INDEMNIZACIÓN
Nombre del estudiante: _______________________________________________Escuela: ____________________________
Patrocinador Docente: _________________Fecha/Hora de salida: ________________Fecha/Hora de regreso:
Itinerario/Destino/Naturaleza de la actividad: __________________________________________________
___________________________________________________________________________________________________
Yo entiendo que existen riesgos y peligros inherentes a la participación en una actividad extracurricular fuera del Condado de Santa Clara debido al
creciente potencial de violencia anti-estadounidense, incluyendo actos terroristas en contra de los ciudadanos de E.U.A., como resultado de la acción
militar en Iraq. También entiendo que para que se me permita participar en esta actividad, yo reconozco explícitamente que el Distrito Escolar
Unificado de San José, sus Representantes, empleados y voluntarios no son responsables de ninguna lesión o daño que pudiese yo sufrir mientras
participo en esta actividad. Sabiendo esto y en consideración de que se me permita participar en esta actividad, por medio del presente Contrato,
libero voluntariamente al Distrito Escolar Unificado de San José, sus Representantes, empleados y voluntarios de cualquiera y de toda
responsabilidad que sea resultado o surja de mi participación en esta actividad.
Yo entiendo y estoy de acuerdo en que este Contrato tendrá el efecto de liberar, eximir, renunciar y para siempre ceder cualquiera y todas las
acciones o causas de acción que yo pudiera tener o haya tenido, ya sea en el pasado, presente o futuro, ya sean conocidas o desconocidas, y ya sea
que sean anticipadas o inanticipadas por mí, como resultado de mi participación en esta actividad. Esta liberación constituye una liberación completa
que exime y cede cualquiera y todas las acciones o causas de acción en contra del Distrito Escolar Unificado de San José, sus Representantes,
empleados y voluntarios.
Yo entiendo y estoy de acuerdo en que este Contrato es aplicable a la lesión personal, daño a la propiedad, o muerte por equivocación, que podría yo
sufrir, aún cuando fuese causada por los actos negligentes u omisiones de otras personas. Yo entiendo y estoy de acuerdo en que al firmar este
Contrato, estoy asumiendo completa responsabilidad de cualesquiera y todos los riesgos de muerte o lesión personal o daño a la propiedad que
pudiese yo sufrir mientras participo en esta actividad. Yo entiendo y estoy de acuerdo en que al firmar este Contrato, estoy de acuerdo en liberar,
indemnizar y considerar al Distrito Escolar Unificado de San José, sus Representantes, empleados y voluntarios totalmente libres de cualesquiera y
todas las responsabilidades o costos, incluyendo costos de abogados, asociados con o que surjan de mi participación en esta actividad.
Por medio del presente Contrato doy mi autorización al Distrito Escolar Unificado de San José, sus oficiales, agentes o empleados, para que hagan
los arreglos, si llegase a ser necesario, para mi tratamiento médico bajo mi propio costo. En caso de que yo esté incapacitado(a) para dar
instrucciones para mi cuidado médico, se le da completa autorización al médico certificado y/o cirujano con quien me lleven, para que me trate, me
administre drogas y medicamentos y realice el tratamiento quirúrgico, de acuerdo a lo que él o ella considere que requiere la emergencia existente,
para el alivio del dolor y/o preservación de mi vida y/o salud y bienestar. Yo entiendo que esta autorización se da con anticipación de cualquier
diagnóstico específico, tratamiento o cuidado hospitalario que se requiera; en su lugar es dado para proveer la autoridad y el poder al Distrito Escolar
Unificado de San José de estar en una posición en la que pueda hacer los arreglos necesarios para intentar asegurar un cuidado razonable bajo
circunstancias de emergencia. Cualesquiera costos en los que se incurra en esta conexión que no cubra mi seguro médico, serán pagados por mí.
Yo entiendo y estoy de acuerdo que este Contrato me comprometerá a mí, mis padres y hermanos, esposo(a), mis herederos, mis representantes
personales, mis asignados, mis hijos y cualquier tutor para un litigio para dichos hijos. Yo entiendo y estoy de acuerdo en que si firmo este Contrato
a nombre de mi hijo/hija menor de edad, estaré renunciando a los mismos derechos para dicho menor de edad como si lo hiciera al firmar este
documento a mi propio nombre.
Yo reconozco que he leído este Contrato y el Aviso de No-Responsabilidad y que entiendo las palabras y el lenguaje en él. Yo he sido informado de
los peligros potenciales incidentales a la participacion en esta actividad. Yo reconozco explícitamente que mi estudiante o yo mismo(a) está/estamos
participando en el evento voluntariamente, y que yo asumo todos los riesgos para mi hijo/hija, incluyendo cualesquiera daños que resulten de actos
intencionales, negligentes, terroristas u otros actos u omisiones, incluyendo actos de guerra. Yo entiendo que este evento no es patrocinado por la
escuela y por medio del presente Contrato asumo toda la responsabilidad por el cuidado de mi hijo/hija o de mí mismo(a) en la duración de este
evento.
Declaración de buena salud: El/la participante, o su padre, madre o tutor declaran que él/ella se encuentra en buena condición física para participar
en esta actividad. Si dicha condición física cambia, el/la participante se retirará de la actividad.
Se le aconseja, por el presente, a cada participante, que consulte a un médico antes de inscribirse a una actividad que requiere mucho esfuerzo físico.
LIBERACIÓN DEL PADRE, MADRE O TUTOR:
Yo soy la madre, el padre o el tutor/tutora legal del menor de edad _____________________, y estoy firmando este documento a nombre de dicho
menor de edad.
Escriba el nombre de madre, padre o tutor con letra de molde:___________________Firma de de madre, padre o tutor_ _______________
Fecha
LIBERACIÓN DEL ESTUDIANTE
Yo, ___________________________, soy un estudiante de 18 años de edad o mayor y estoy firmando este documento a mi propio nombre.
Escriba el nombre del estudiante adulto con letra de molde: _______________________________________________
Firma del estudiante adulto: ________________________________________________________________________
Fecha

San Jose USD
Board Policy
School Sponsored Trips
Instruction
The Governing Board recognizes that school-sponsored trips are important
components of a student's development.
They fall into two categories: (1) those related to the instructional program
(Instructional Trips), (2) other trips for students with a school-affiliated group.
Where possible, Schools are encouraged to use buses as the mode of
transportation for these trips.
BP 6153
Student participation in instructional trips may or may not be voluntary and no
costs may be charged to any individual student. District general funds may be
used to cover the costs of these trips. In addition, funds to meet the costs of
these trips may be raised by donations or fund-raising, through approved
activities, by organizations, entities, or individuals.
Participation in other trips is voluntary. Examples of "other" trips are included in
the administrative regulations. The costs will be paid from sources other than
district general funds. Although funds may come from donations and schoolrelated
support groups, the Board encourages the members of the participating
group to obtain the funds through group endeavors. No otherwise eligible
member of a participating group may be excluded if that member participated in
the fund-raising activities of the group designed to pay the costs of the field trip.
Staff and students are encouraged to plan all trips so that no more than one day
of instruction will be missed by students, and the trip is within 100-mile distance
of the district.
Special trip expense funds may be established when necessary for fund-raising
purposes.
(cf. 1321 - Solicitation of Funds from and by Students)
(cf. 6145 - Extra-curricular and Co-curricular Activities)
All trips involving out-of-state or overnight travel shall require the prior approval of
the Board. Other trips may be approved by the Superintendent or designee.

Principals shall ensure that teachers develop plans which provide for the safety
of students and their proper supervision by certificated staff on all schoolsponsored
trips. Other school employees and parents/guardians also may
participate in this supervision and may be asked to attend preparatory training
sessions and/or meetings. Students with special needs may require additional
adult support per the student's IEP.
The ratio of adults to students on school-sponsored trips shall be at least one
adult per five students, grades K-12 and one adult per 10 students, grades 3-12,
with a minimum of two adults is required for continuous monitoring of students. If
the trip involves water activities, this ratio shall be revised to ensure closer
supervision of elementary grade students, appropriate to their ages.
(cf. 3541.1 - Transportation for School-Related Trips)
(cf. 5143 - Insurance)
Study Trips
In advance of a study trip, teachers shall determine educational objectives which
relate directly to the curriculum. Principals shall ensure that teachers develop
plans which provide for the best use of students' learning time while on the trip.
Teachers also shall provide appropriate instruction before and after the trip.
Legal Reference:
EDUCATION CODE
8760 Authorization of outdoor science and conservation programs
32040-32044 First aid equipment: field trips
35330 Excursions and field trips
35331 Provision for medical or hospital service for pupils (on field trips)
35332 Transportation by chartered airline
35350 Transportation of students
44808 Liability when pupils not on school property
48908 Duties of pupils; authority of teachers
BUSINESS AND PROFESSIONS CODE
17540 Travel promoters
17550-17550.9 Sellers of travel
17552-17556.5 Educational travel organizations
Management Resources:
WEB SITES
American Red Cross: http://www.redcross.org
California Association of Directors of Activities: http://www.cada1.org
U.S. Department of Homeland Security: http://www.dhs.gov

Policy SAN JOSE UNIFIED SCHOOL DISTRICT
adopted: September 20, 2001 San Jose, California
revised: February 27, 2003
revised: September 4, 2008

San Jose USD
Administrative Regulation
School-Sponsored Trips
Instruction
AR 6153
All planned trips away from school grounds including athletic trips and outdoor education programs are subject
to this regulation.
In the event that athletic competitions exceed the 100 mile radius and/or include an overnight stay, this
regulation applies.
Students must have written parental permission in order to participate in trips requiring transportation.
(Education Code 35350) The district shall provide an alternative educational experience for students whose
parents/guardians do not wish them to participate in a trip.
General Procedures
1. Trips taken within Santa Clara County, the teacher must secure approval of the principal prior to the
activity.
2. All trips taken beyond Santa Clara County and within a 100 mile radius of the school, the teacher must
secure approval of the Principal and Director, Division of Instruction, two weeks prior to departure. An
itinerary of the trips is to be maintained in the school office.
3. All trips beyond the 100-mile radius, an overnight trip, regardless of distance, or is out-of-state, Governing
Board approval is required.
a. Procedures and time requirement must be followed to place the request on the Board agenda one month
prior to the date of the trip.
b. Athletic competition activities are restricted to grades 8-12. (Special appeals to this guideline may be
made on a case-by-case basis.)
Exception: Out-of-state trip requiring fundraising over $5,000 requires approval by the Board four months prior
to the activity.
Insurance Coverage
Student accident insurance is provided to meet the California Education Code requirements for insurance
coverage. The California Education Code requires that all students must have insurance to go on field trips.
San Jose Unified School District provides this coverage on all one day field trips when there is direct and
immediate supervision by school personnel. This means approximately one adult supervising ten students at
all times.
Safety and First Aid
All other field trips must have additional insurance purchased through the Risk Management Department prior
to the field trip. The short term (24 hour) coverage provides excess accident and acute illness medical
coverage and accidental death and dismemberment coverage for students participating in school sponsored
and supervised activities involving overnight travel and/or periods without direct and immediate school
supervision. There is a small rate for this coverage. Coverage consists of basic and catastrophic injury benefits.
1. While conducting a trip, the teacher, employee or agent of the school shall have the school's first aid kit in
his/her possession or immediately available. (Education Code 32040, 32041)
2. Whenever trips are conducted in areas known to be infested with poisonous snakes:
a. The first aid kit taken on the trip shall contain medically accepted snakebite remedies. (Education Code
32043)

. The trip shall be accompanied by a teacher, employee or agent of the school who has completed a first
aid course which is certified by the American Red Cross and which emphasizes the treatment of
snakebites. (Education Code 32043)
3. Before trips of more than one day, the principal or designee shall hold a meeting for staff, parents/
guardians and students to discuss safety and the importance of safety-related rules for the trip. For non
certificated adults who will assist in supervising students on the trip, the principal or designee may also
hold a meeting to explain how to keep appropriate groups together and what to do if an emergency
occurs.
4. Student's medical forms should be reviewed before trip for special needs.
Supervision
1. Students on approved trips are under the jurisdiction of the Governing Board and subject to school rules
and regulations.
2. Teachers or other certificated personnel shall accompany students on all trips and shall assume
responsibility for their proper conduct.
3. Before the trip, teachers shall provide any adult chaperones who may accompany the students with clear
information regarding their responsibilities.
4. Health and medical insurance information must accompany trip leader(s)
5. At least one adult per five students, grades K-2 and one adult per ten students, grades 3-12, with a
minimum of two adults is required for continuous monitoring of students. Students with special needs may
require additional adult support per the student's IEP.
6. Teachers and chaperones shall not consume alcoholic beverages or use controlled substances while
accompanying and supervising students on a trip.
7. When a trip is made to a place of business or industry, the teacher shall arrange for an employee of the
host company to serve as conductor.
Funding
No student shall be prevented from making a trip because of a lack of sufficient funds. No trip shall be
authorized if any student would be excluded from participation because of a lack of sufficient funds. (Education
Code 35330)
All funds raised toward a given trip and not utilized by individual students for that particular trip should revert to
the scholarship fund.
Examples of other educational trips for which students may be assessed charges:
1. Transporting students to be spectators at school contests or competitions.
2. Trips after school and on weekends by clubs and/or student groups to museums, parks and other
locations.
3. Minimum district insurance coverage will be included in the trip cost.
Instructional Time
1. Educational trips may take no more than three instructional days. Trips requiring more than three days will
be considered by the Board on a case-by-case basis.
2. It is recommended that extended trips be taken during winter, spring and summer breaks,
Trip Approval
1. The principal shall approve or disapprove the request and notify the teacher. If the trip is disapproved, the
principal should state the reasons.

2. Principals may exclude from the trip any student whose presence on the trip would pose a safety or
disciplinary risk.
3. Principals shall approve no activities which they consider to be inherently dangerous to students or to
pose unacceptable, unmitigated risks.
4. A parent/guardian permission statement must be secured from the parent/guardian in advance for any
educational trip:
a. The principal may authorize participation if telephone approval from the parent/guardian has been
received for local trips only.
b. A written confirmation of telephone approval will be sent to the child's parent/guardian.
Blanket Approvals
Principals or designees will prepare and forward a completed educational trip form for a "blanket" approval
request from the Board whenever it is anticipated that a school athletic team or other student group will place in
semi-final or final competition and for completion of special preapproved projects. The dates for these
qualifying activities are not known in advance.
1. Athletic tournaments
2. Agriculture and other educational projects
3. Other: Camp Campbell/Walden West counselors, state, national and international competitions
Educational Expectations and Structure for Out-of-State Trips
1. Educational trip structure must meet with the following criteria:
a. Pre-activities:
(1) Student behavior and eligibility
(a) It is expected that students have demonstrated personal responsibility and positive behavior during the
period preceding the activity. Whenever there is a question regarding the student's ability to behave
responsibly during an educational trip, the student's eligibility may be addressed by a Review Committee
as necessary.
(b) District behavior policies shall be fully enforced and implemented:
* 1st offense - warning
* 2nd offense - call home by student and trip leader
* 3rd offense - student goes home at parent expense
(c) Immediate Go Home Behavior
* Drugs, alcohol, weapon possession
* Person/property damage
* Unauthorized diversion from trip itinerary (unsupervised areas off hotel grounds)
(d) A behavior contract must be signed by parent/guardian acknowledging guidelines.
(2) Teacher approval on field trip form must be obtained.
Credit for make-up assignments to be given upon completion of work (2 weeks upon return).
(3) Teacher leader establishes educational guidelines, format and itinerary of trip and submits his information
in writing to site administrator, attached to request for Board approval.

(4) Site administrator approves the activity and forwards request to the appropriate administrator in
Educational Services Division within Board-approval timelines.
(5) Introductory letter to parents or guardians and/or meeting is held, preceded by a public announcement to
all students.
(a) The information provided to parents/guardians is to contain the following: itinerary, dates, cost and
scholarship availability and eligibility, payment dates, fund-raising activities, standards for trip, including
medical, behavioral, educational expectations, and sponsoring company policies.
(b) Any applicable deadlines.
(6) Trip leader holds an educational orientation meeting prior to departure.
(7) Additional insurance must be purchased if a student does not have insurance.
(8) When participating in an activity that holds risks and dangers, (i.e. kayaking, biking) a Waiver Release
and Indemnity form will be signed by parent releasing San Jose Unified of all liability while participating in
this activity.
2. Educational Expectations: The following minimum accountability is required for all trips taken during
instructional time and is also highly recommended for trips taken during vacation time:
a. Students may keep a daily student trip journal to reflect educational experiences.
b. It is mandatory that each student participate in all activities listed on the approved itinerary.
3. Evaluation
a Trip leader will maintain evidence of successful completion of itinerary to include daily student journals
and other documentation available upon request.
b. Trip leader may provide an optional photo display.
Fees and Fund-Raising
1. If there is a request for a trip that involves an extended distance, such as Washington, D. C. and/or an
absence of several days from instruction by students, the Board must give approval before any plans to
implement the request are initiated. A request for such a trip should be submitted to the appropriate
administrator in the Educational Services Department four months before the trip is to take place.
a. No fund-raising shall begin until approval has been obtained from the Board.
b. Written parent/guardian permission slips are required for all trips requiring Board approval.
c. Health information form must be completed prior to trip.
d. Out-of-state and overnight trips will require minimal medical insurance, as facilitated by the district.
e. Waiver is required.
2. A first aid kit needs to accompany each trip leader for all trips.
3. A first aid kit needs to accompany each trip leader for any trip requiring Board approval.
Qualifications for Out-of-State Trip (Leader(s))
1. Must be a District certificated employee.
2. Site-based, experienced teachers will be given priority.
3. Knowledge of district field trip policies and guidelines as determined by site administrator.
Inservice

1. Inservice will be provided for certificated staff without prior out-of-state experience and who are interested
in becoming out-of-state trip leaders.
2. Inservice will be provided for teachers and on-site and off-campus coaches regarding Board policy and
administrative guidelines for educational trips.
Transportation
1. Procedures for use of private cars to transport students on trips:
a. Written notification of the assumption of liability by the driver must be on file at the school office prior to the
trip.
b. Volunteer drivers and school staff must show proper vehicle insurance ($100,00/$300,000) before driving
on a field trip. Insurance papers must be kept on file in the school office for all field trips drivers.
c. For trips over 100 miles or out of state, proper vehicle insurance $1,000,000) must
be shown. Certificate of Insurance must be attached to Volunteer Driver Form
d. The number of passengers per vehicle shall not exceed the number of seat belts provided and these must
be used.
e. Once per year, drivers licensed by the State of California who transport students must provide a copy of
their driving record as issued by the Department of Motor Vehicles.
f. A release of liability form will be signed by the parent/guardian transporting students and licensed by the
State of California who meet minimum requirements described in a-d above.
g. A release of liability form will be signed by the parent/guardian of students riding with drivers transporting
students who meet minimum requirements described in a-d above.
h. Students are not permitted to drive other students to school sponsored events.
Students must have written parental permission in order to participate in trips requiring transportation.
(Education Code 35350) The district shall provide an alternative educational experience for students whose
parents/guardians do not wish them to participate in a trip.
The Superintendent is authorized to approve some educational trips a case by case with supporting
documentation, whenever the Board approval time lines cannot be met.
Regulation SAN JOSE UNIFIED SCHOOL DISTRICT
approved: September 20, 2001 San Jose, California
revised: February 27, 2003
revised: September 4, 2008

FIELD TRIP GUIDELINES ATTACHMENT A
TYPE OF FIELD TRIP DISTRICT ADDITIONAL WAIVER BOARD AGENDA
During the school day, in county, supervised
i.e. Tech, Museums, Tours, etc.
YES NO
During the school day, in county, unsupervised
i.e. Raging Waters, Great America, Golfland, etc.
NO YES*
During the school day, out of county, supervised
i.e. Monterey Aquarium, SF Zoo, etc.
YES NO
During the school day, out of county, unsupervised
i.e. Competition or tournament in SF
NO YES*
Overnight, District sponsored, in county
i.e. Competition or tournament
NO YES*
Overnight, District sponsored, out of county
i.e. Camp Campbell, Redwood Glen, etc.
NO YES*
INS. INS. REQUIRED REQUIRED ACTION REQUIRED
NO, unless risks
involved NONE
NO, unless risks
involved NONE
NO, unless risks
involved Board Action Required
NO, unless risks
involved Board Action Required
NO, unless risks
involved Board Action Required
NO, unless risks
involved Board Action Required
Non-school day, District sponsored, in county, YES NO NO, unless risks NONE
supervised involved
i.e. Tournament or classroom practice
Non-school day, District sponsored, in county,
or out of county, unsupervised
I.e. Tournament without supervision of 1/10
NO YES*
Non-school day, District sponsored, in or out of
county, supervised
I.e. Tournament with 1/10 supervision
YES NO
NO, unless risks
involved
NO, unless risks
involved
Board action item required for out of
county trips
Board action item required for out of
county trips
ALL trips involving water, supervised or not NO YES* Waiver required Board Action Required
Amusement Parks, Bay Cruises, Whale Watching,
River Walks, etc.
*For additional insurance, contact Risk Mgmt. All non-District sponsored trips (cheerleading competition, carwashes, fundraisers) must be insured
through Home & School Clubs, PTA’s, Foundations or Booster Clubs. Orange Alert is considered “RISK” & waivers are required. RED Alert-all trips cancelled.
RisK Management 12/28/10

San Jose Unified
School District
AUXILIARY SERVICES
RISK MANAGEMENT DEPARTMENT
2222 Unified Way, Building T ● San Jose, California 95125 ● (408) 535-6510 ● Fax (408) 297-9849
“Inspiring and Preparing for Success”
ACKNOWLEDGEMENT OF NON-SPONSORSHIP OF ACTIVITY OR TRIP
BY SCHOOL DISTRICT
Note: This is a binding legal agreement. You may wish to consult with your attorney
before executing this agreement.
I, ____________________________(parent/guardian), fully understand and acknowledge that the
activity or trip that my child, _____________________________________, is participating in on
________ (date) to _____________________(location) is not sponsored or connected or in any way
required by __________________________(“School District”). I fully understand and acknowledge
that ________________________(person organizing activity or trip) is not acting in his or her official
capacity as a “School District” employee in organizing and in supervising this activity or trip.
Likewise, I fully understand and acknowledge that _____________________ (person organizing
activity or trip) is acting on his or her own time in organizing and supervising this activity or trip.
I fully understand and acknowledge that under California Law, the “ School District” cannot be held
liable for any accident, illness, injury or death to my child arising from the participation in this
activity or trip.
I hereby voluntarily release, waive and relinquish any and all claims and causes of actions against
the State of California, _______________________ School District and all employees, officers, board
members and agents acting in their capacity as representatives of ____________________
School District, which may hereafter arise on behalf of myself, _________________________ (my
minor child), my heirs and representatives, or the heirs and representatives of my child for accident,
illness, injury or death arising from the participation of my child in the herein referenced activity
and/or trip whether the same shall arise by negligence or by any other cause.
I acknowledge that I have read this Acknowledgement of Non-Sponsorship of Activity or Trip by
____________________ School District and that I have been advised that I may wish to consult my
attorney regarding the legal consequences of signing this Acknowledgement.
PLEASE PRINT ___________________________________________________________
Student’s First and Last Name
_________________________ __________ __________________________ ________
Signature of Parent/Guardian Date Signature of Student Date
________________________ __________ __________________________ _________
Signature of Parent/Guardian Date High School Attending Grade
Distribution: School Site/Parent/Guardian/Student