Western Dubuque County Community School District
Field Trip Request Form Parochial (When Traveling Less than 500 Miles from Dubuque) Form
2/17/2019

Western Dubuque School District

Field Trip Request Form for PAROCHIAL USE ONLY (When Traveling Less than 500 Miles from Dubuque)

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NOTE: Trips outside of the continental United States or travel outside of 500 miles from Dubuque must be made on the "International or Extended Domestic Travel Student Trip Proposal" and require Board approval 6 months prior to the proposed date of travel.

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Teacher/Coach First Name
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Teacher/Coach Last Name
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Grade/Group

If other, please specify
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Trip Leave Date (mm/dd/yyyy)
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Trip Return Date (mm/dd/yyyy)
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School Name
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Number of School Days Absent
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Activity
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Destination name and address (Include street address, city, state, zip)
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Brief explanation of purpose of this trip
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Trip Leave Time
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Approximate Trip Return Time at Schools
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Approximate number of miles from Dubuque
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Charges
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Please explain cost details (i.e. registration costs, travel costs, lodging, meals, subs, etc.)
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Paid for by details (i.e. district, students, employee, activity group, etc.)
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Approximate Number of Riders and Bus(es) Needed

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No. of Students
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No. of Adults as Chaperones
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No. of Bus(es)
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No. of Vans and/or Suburbans
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No. of Personal Vehicles
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Yes  No  
Are Lift Bus(es) Needed
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No. of Wheelchair Students
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Trip Costing


Round Trip Mileage
Mileage Cost per Bus $:

Trip Time (Number of hours from Trip Leave Time to Trip Return Time) Round to nearest quarter of an hour. (.25, .50, .75)
Cost per Driver $:

Mileage Cost per Bus

Cost Per Driver

Number of Bus(es)
Total Cost Estimate $:

Total Estimated Cost

Number of Students
Cost per Student $:
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For Transportation Office Use Only

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Driver(s) Assigned & Miscellaneous Information
Routing Instructions
Transportation Dept.
Complete the information below to route your form. * Indicates Required Fields
Your Name:
* Your E-mail: *
Confirm E-mail: *
Send to Approver:  
No approver has been assigned to this form, please contact your District Forms Manager.