...
.A
/:-..\
ATHlETICS
..OSD
--_.-.-
& ACTIVITIES
•
OFF-CAMPUS TRIP REQUEST
SCHOOL
Olympia
High
DEPARTURE
School
DATE
SPORT/AcrrvrrY
REQUEffiO By
DESTlNA110N
Boys
Jesse
SpokanrWA
I,4/22/2017
I 11:00pm
TIME
RETURN DATE
I.TIME
2:45pm
4/21/2017
Track
Stevick
I
CHECK IF OVERNIGHT
PERSON(')
INCHARGE
Jesse Slevlck
PuRPOSE OF TRIP (FULL ITINERARY MUST BE AnACHEo)
Travel to the Mooberry
1# STAff OtAPfRONE5
##$TUDENTS
/
WA
Relays in Spokane,
# VOWNTEER CHAPIRONES
NAMES OF ADULT CHAPERONES
Jesse Stevick
28
M:
F:
M:4
F:
1
M:
F:
ADDITIONAL CoNTACT PHONE Its
PRIMARY CELL PHONE CoNTACT #5
(360) 918-1255 (509) 777-1000
(note "5"for School Staff or "V"for Volunteer; 1:1 ratio required/or overnight)
=s-
Drew Stevick
S
Greg Hargrave
s;
Mat! Hankins
s
Cassidy Stevick
s
'Supervisor Initial
/
The following Items have been completed and flied with the site Athletic Director:
• Complete itinerary with supervision plan of activities, including off-field aetlvltles--must be part o/thls request, attached or on reverse .
Complete list of all participants and signed permission slips
Transportation
arranged and approved by the site Athletic Director
•
lodging arranged and approved by the ,Ite Athletic Director (If overnight)
The current participation list has been reviewed for any health condition updates, with changes noted In writing and maintained by the supervisor In charge
A
•
rr
•
-:t"
'l'A
Participants requiring medication have all permission forms on file (self-administered or other) and medication provided prior to departure
;Trlp Expenses - be specific: school bus/charter
bus/auto/plane,
etc.; name of hotel/motel/hostel,
$
TRANSPORTATION
School Bus to Spokane, WA (689 x 1.37 per mila)
944
$
MEAlS
etc.; meals individual/group, etc.
$
HOUSING
1 room x 1 night at x $134
150
OTHER
Bus Drive Pay' (2 days x 24.96 par hour x 10 hrs a day)
SOD
$ Appro,.$1,594
TOTAL
:Source of Funds
BUILDING
Accr #
$
ASBACCT.#
7'Qe~Jd80e>7a.J(
$
".For,
INDIVIDUAL STUDENT
~~,~
DA
OLYMPIA
SO/OOl DISTRICT
$
$
$
OTHER
ESsl ATHLETICS
OAT<
JUlY2D15
SUPERVISIONAND PLANNING
Basics:
1.
2.
3.
No participant is to be unsupervised at any time.
All supervisors must be OSD coaches or District-approved volunteers.
Pians are in place In case of emergency - injury, Illness, etc.
Itinerary:
1. Detail from time of departure to time of return.
•
•
2.
3.
4.
Rules:
1.
Include transportation, practices, meals, meetings, etc... location, date, time
Include non-practice times
•
Include supervision plan for each activity .... who and how
The detailed itinerary Is distributed to parents prior to departure.
Participants are expected to travel to and from games/practice locations as a team.
Independent travei is authorized on a limited basis following approved District procedures.
Expectations for behavior are clearly provided to all participants
and parents in writing prior to departure and verbally reinforced daily.
lodging:
1. A room list is developed with copies to the site AD.
2.
Supervisors' rooms are located in close proximity to those of participants.
3.
Room checks are made at a specified hour per itinerary.
CommunIcation:
1. Notification
contact.
methods are in place and communicated
so both students and parents know where the supervisors are at all times and how they may make
SupeNision:
1.
2.
3.
4.
S.
Assigned supervisors must be current OSD coaches or District approved volunteers.
All assigned supervisors have accepted the responsibility and clearly understand all duties and expectations.
Supervision for non-participating students; N/C players (traveling with varsity), sick/injured players is planned for and provided.
Supervision plans and itinerary include supervision responsibilities to ensure all athletes have safely left the facility before the supervisor leaves.
All supervisors (paid and volunteer) have knowledge and understanding of their duties and accept their responsibilities. Further, all supervisors (paid and
volunteer) have knowledge and understanding of all applicable policies, procedures, rules and regulations of the WIAA and Olympia School District (including,
but not limited to: Policy S201-Drug Free Workplace; Policy S2S2/S253;--Professional Boundaries; and Policy 3421/3421P-Child
Abuse Reporting.
I understand and acknowledge the above requirements,
Head/Lead supervisor/org~iZe~
Reviewed By Site AD:
OLYMPIA
SCHOOL DISTRICT
~
Signat~_~~_~
responsibilities
rC/!
and duties and ensure all requirements
_
Date
_
Date
are in place and will be adhered to.
JULY2015
Mooberry Relays Tentative Itinerary
April 21" - 22"d , 2017
OHS track team
Friday, April 21"
2:45 PM - Leave OHS in bus
5:30 PM - Stop in Ellensburg for dinner
8:45 PM - Arrive at Whitworth University. Check in with Whitworth tours department to sleep in
Ballet loft
10:45 PM - All athletes in ballet loft for sleep, checked by supervisors
Satu rday, April 22'd
7:30 AM - Breakfast in Whitworth Dining commons
9:00 AM - depart Whitworth for track meet at Rogers High School
5:00 PM - Depart after conclusion of track meet for Olympia
7:00 PM - Stop in Ellensburg for dinner
11:00 PM - Arrive back at OHS. Supervisors stay with students until all are picked up from OHS
campus.
During all portions of the trip, athletes will be directly supervised by coaches, and when stopped for
dinner in Ellensburg athletes will stay in groups of at least six, and each group will stay with
assigned supervisor. Each group will be allowed thirty-five minutes to obtain food from several
restaurants within a three block radius.
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