Western Dubuque County Community School District
International/Extended Domestic Travel Student Trip Proposal (Travel 500+ Miles from Dubuque) Form
5/23/2019

International or Extended Domestic Travel Student Trip Proposal

Western Dubuque School District

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Definition: International or extended domestic travel is defined as all travel to areas outside of the contiguous 48 states or travel over 500 miles from Dubuque.

Requests for approval of student travel outside the continental United States or travel outside of 500 miles from Dubuque require Board approval. Requests must be submitted at least six (6) months prior to the proposed dates of travel. No commitments may be made or fundraising initiated until all required approvals have been secured. No extracurricular trips will be approved for international or extended domestic travel more than twice in a four-year-period unless they are curriculum related. No student will be approved for the same activity to attend more than twice in a four-year-period any international or extended domestic travel student trip. Refer to Board Policy number 606.5 for specifics.
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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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Trip Return Time at Schools
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Approximate number of miles from Dubuque (one way)
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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.)
Will this be a combination trip with another school?: *
Yes  No  
If yes, indicate other school:
Will school funding of any kind be used?: *
Yes  No  
If yes, explain:
Financial benefit to sponsor for participation in this trip:
Transportation needed (check all that apply): *
Air  Charter Bus  
Rental Van  School Bus  
School Suburban  School Van  
Name/address of agency (if any) involved in trip management:
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Approximate Number of Riders and Bus(es) If 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
Cost per Bus $:

Cost per Bus

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
This form must be submitted for Board approval at least six months prior to the date of requested travel.
Complete the information below to route your form. * Indicates Required Fields
Send to Approver:  
No approver has been assigned to this form, please contact your District Forms Manager.