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Colchester Public Schools *
Application for Approval of Field Trip
Overview: This form must be completed by all staff to request approval of a field trip.
Directions:
1. Complete the form attaching all applicable documentation and submit to your administrator. The application
must be submitted at least two weeks prior for in-state field trips, and two weeks and two months prior for
out-of-state trips.
2. The Administrator will recommend or not recommend. If approved, the form must be sent to the
Superintendent.
3. The Superintendent will either recommend or not recommend and will bring to the Board of Education if the
request is for an out-of-state field trip.
4. |f applicable, the Board of Education reviews and makes the final decision.
Today’s Date; 1-27-2022
Field Trip Information
Applicant Name: 7 Kegler Method of Maeno fon: Kys ore fod yee
School: BA Bus Service Number(s) ikgeplicable): Blof Dal
Grade(s) and Group(s): }a77 BAND Gr 10-12 Number of Students: 99 See
Date(s) of Trip: Saturday, April 9, 2022 Number of Day(s) of Trip: 1
Event: Umass Amherst Jazz Festival
Destination: : Phone Number:
UM ek NEP T ot M vSIC 860-437-6956
Address [St PRESISEAZS 2a State: M A
(for each destination): Ad HER ST. hd CCD 3 6330
Time of Departure From Schodl: 8AM Special Clothing and/or Equipment Required:
Time of Arrival Back at School: 5PM As necessary
Student Cost Information
*Cost to Student: $ 99 Suggested Student Pocket Money: $ 20
Supervision Information iene Cone Meissen sie y Tes) phone number for each)
1. Name: T Kessler Cell Phone: =
2. Name: id. CHEAEY Cell Phone:
List all adult chaperones: Ratio of adult chaperones to students must be at least: 1:5 for Grades K-2, 1:8 for Grades 3-5; 1:10 for
Grades 6-8; and 1:15 for Grades 9-12 (one-day trips) or 1:10 (overnight trips)
Administrator Signatures
Applicant Signature
Administrator’s ae res ended i Not Recommended
Recommended E Not Recommended
Superintendent’s Signature
Board of Education (haere)
Board of Education Meeting Date: [ | Recommended (| Not Recommended
Bus Information
Bus Reservation Date: Price of Bus(es): $
*If a trip to a foreign country, please complete and attached the CIRMA insurance application and notify parents of coverage Last Updated 5/27/21
Field Trip Instructional Plan
Colchester Public Schools
Field Trip Location(s); UMass Amherst
Reference Check: Visited site on: Tse or Spoke with: Proff. Jeff Holmes
T Kessler 10-J2
Name:
Grade/Group:
(Teacher(s) completing this form)
Instructional Focus of Trip
@ This field trip is directly related to curriculum Mi Yes [] No
® Curriculum Unit(s): Perform
Specific Curriculum Standards Addressed by Field Trip (please refer to CT Core and disciplinary standards):
Perform for audience and for Judges
Listen to other bands
Assessment of Student Learning (describe or attach the work students will complete upon their return to
convey the learning):
Judge's assessment
Trip Agenda/Activities: List/attach entire break out of times for each day. Include travel time and all activities.
Attach additional sheet if needed.
DATE/TIME LOCATION ACTIVITY
8AM 3-25 BA Auditorium Pick up
10AM UM Arrival
Noon UM Performance
1PM UM Clinic
3PM UM Prepare to leave
5PM UM BA/Home
Approvals: Bee au 1.27.22 [ lapproved | |oenie
Department Chair (High School Only) Date
wa
if ofr [Paproved | Jpenied
renee] Date
= FTaporoved [ |oenied
birector 2. nm and Learning Datle
Undated 5.27.21
Field Trip Cost Form
Date(s) of Trip: mm APRIL q 2022
Event: UMass Amherst Jazz Festival
Mé&J Bus(es) ONLY
Number of Students: Estimated Hours for trip: 399
(Add 1 hour pre/post trip)
20
Number of Buses: 4
Per Student Calculations:
M&J Bus(es) ONLY Coach Bus(es) ONLY
Admission per student: 40 i
Miscellaneous Fees per student: 10
Total admission and miscellaneous fees: $200
Cost of Bus $300
Total Field Trip *Cost per Student: $25
Additional Costs:
Number of Substitute Teachers 0
Rate per Day
Special Education costs
Cost Associated if Nursing Required
Total *Cost to District: $500
Total *Cost of Trip: $500
Alternate funding for trip provided by:
*Insert these costs on the accompanying Field Trip Application
Form updated 5.27.21
4 <9 (veoeaaren OVEF
24th ANNUAL UMASS HIGH SCHOOL JAZZ FESTIVAL
SATURDAY APRIL 9th, 2022 UMASS MUSIC DEPT
School,
Director,
School Address.
Phone.
E-Mail
Number of Ensembles
$175 for one ensemble; $150 each for two or more
Approx total Number of students and chaperones/directors,
any special needs?
Checks should be made out to: University of Massachusetts Amherst
Memo: High School Jazz Festival 2022
Deadline for form and payment: March 18, 2022. Please mail to:
Andrew Wilcox
Dept of Music & Dance — 273 East
151 Presidents Dr. Ofc. 1
University of Massachusetts
Amherst, MA 01003-9330
Contact info: Andrew Wilcox (Jazz TA)
umassjazzfest @ gmail.com
NOTE: there is separate admission to the evening concert featuring Anat Cohen
Ticket purchasing info from the Fine Arts Center will be provided in a separate document
If you have any questions about that concert, please contact the Fine Arts Center Box
Office at 413-545-2511
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