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ED169

Updated: 04/12

APPLICATION TO CONDUCT AN EXCURSION


(REFER TO: CAMPS & EXCURSIONS GUIDELINES FOR SCHOOLS AND PRESCHOOLS)
APPLICATION FOR EDUCATION EXCURSIONS:
INTRASTATE TRAVEL (Approved by PRINCIPAL)
INTERSTATE TRAVEL/INTERSTATE USE OF DEPARTMENTAL VEHICLES/BUSES (Approved by REGIONAL DIRECTOR)
OVERSEAS TRAVEL (Approved by CHIEF EXECUTIVE through EXECUTIVE DIRECTOR, PRESCHOOL & SCHOOL IMPROVEMENT).
Refer to overseas travel policy and procedures
SCHOOL/PRESCHOOL NAME:

Flinders View Primary School

NAME OF EXCURSION:

R/1 19 Term 3 Excursion

DESTINATION:

Wilmington
NATURE OF EXCURSION

(a)

Provide an outline of the excursion, including places to be visited and a program of proposed activities. (Attach further sheets if required.)

Bus to Wilmington, eat Recess, visit the Wilmington old Toy museum and the puppet museum, Eat lunch, and return on the bus.
(b) Curriculum Links/Outcomes
History : How the stories of families and the past can be communicated, for example through photographs, artefacts, books, oral histories, digital media, and
museums (ACHHK004) Explore a range of sources about the past (ACHHS018) Identify and compare features of objects from the past and present
(ACHHS019) Differences and similarities between students' daily lives and life during their parents and grandparents childhoods, including family traditions,
leisure time and communications. (ACHHK030) Drama :Present drama that communicates ideas, including stories from their community, to an audience
(ACADRM029) Respond to drama and consider where and why people make drama, starting with Australian drama including drama of Aboriginal and Torres
Strait Islander Peoples (ACADRR030) Explore role and dramatic action in dramatic play, improvisation and process drama (ACADRM027) Design and Tech:
Identify how people design and produce familiar products, services and environments and consider sustainability to meet personal and local community needs
(ACTDEK001) Explore how technologies use forces to create movement in products (ACTDEK002)
(c)

Dates (Inclusive)

From:

or

to:

BREAKDOWN OF COSTS AND CHARGES


If the camp/excursion is:

predominantly educational, GST must be added to the food charge, but all other
charges to students are GST-free

not predominantly educational, eg predominantly recreational, GST must be added to


all student charges.
GST exclusive cost
per student
Food

10% GST (only where


applicable)

$5.90

GST)

22

09

15

NUMBER AND YEAR LEVEL(S) OF


STUDENTS INVOLVED

Charge to student

Year
Level

Male

Female

Total

11

Transport ($1.22 per


km) (($112)($124 w

on:

$6.50

Entrance Fee(s)
($30, $25)

$2

Bus Driver ($80)

$4.12

$12.60

Accommodation

$12

(total cost, $259)

Total charge to student

$5

Total number of students

19

TEACHERS AND OTHER LEADERS QUALIFICATIONS AND RELEVANT EXPERIENCE (ATTACH FURTHER SHEETS IF NECESSARY)
Teacher in Charge

Sage Othams, Master of Education, Senior First Aid certificate

Other Teachers and Leaders


Male/
Female

Status: teacher, SSO,


student, instructor, parent,
volunteer, etc

TN

SSO

Police Check

SN

ACEO

Police Check

AM

Leadership/AET

Police Check

LM

Grandparent

Police Check

Name(s)

Total number of teachers and leaders

Qualifications and experiences in


proposed activities

Current first aid


qualification (in past 3
years)

Minimum number at any one time

Turn to Page 2ED169 Continued


SCHOOL-BASED CONTACT PERSON
DURING EXCURSION

VC
EMERGENCY ACTION

Detail the plan for emergency action should the need arise. All teachers and leaders involved in the program should have this information.
(Attach further sheets if required.)
We will have an allocated fire emergency meet point outside the Toy museum/puppet museum.
We have all the students carers phone numbers
All adults will have a mobile phone.
Sage will be our First Aid officers and we will have a first aid kit with us. We will have all students necessary medication/puffers with us.
We have all the emergency phone numbers for the nearest hospital, doctors, police and ambulance.

TRAVEL ARRANGEMENTS
(a)

Intrastate/Interstate Travel
Mode of travel to be used

Bus

Departure time

3 0 am

Name of bus company/tour operator/airline

and return time

3 0 pm

Port Augusta High School Bus

Phone No

(08) 8647 3312

Private vehicle/name of owner/ registration number (Insurance category: Third party property or comprehensive)
Name of Owner

Registration No

Insurance Category

Name of Insuring Company

(b)

Overseas Travel provide a detailed itinerary of all travel arrangements for excursion. Attach separate sheets including overseas travel
proposals (FORM NP11) completed by each departmental employee.

(c)

Charter air travel indicate why charter air travel is required. (Attach further sheets if required.)

Signature

Teacher-in-charge

Date //

APPROVALS
PRINCIPAL/DIRECTOR APPROVAL FOR CAMP/EXCURSION
Based on the stated curriculum links/outcomes, I certify that this camp/excursion is predominantly educational
Signature

Principal/Director

Yes
Date //

FOR INTERSTATE TRAVEL/USE OF DEPARTMENTAL VEHICLES/BUSES INTERSTATE


Approved/not approved
Signature

Regional Director

FOR OVERSEAS TRAVEL REFER TO OVERSEAS TRAVEL POLICY & PROCEDURES

Date //

No

ED170
Updated: 05/12

CONSENT FORM FOR CAMP/EXCURSION


(To be completed in conjunction with medical information and activity information sheets)
Please use block letters when filling out this form

As a parent/guardian of:
STUDENT/CHILDS NAME

I:
PARENT/GUARDIAN NAME

give my consent for him/her to participate in:


NAME OF ACTIVITY

Room 19 Wilmington Excursion

REASON FOR AND


DESCRIPTION OF ACTIVITY

Travelling to Wilmington by PASS bus, to visit the Wilmington Toy Museum and the Puppet Museum. Links to History,
Drama and Design and Technology.

at/on:
LOCATION

Flinders Rangers (Arkaroo Rock or Sacred Canyon, Wilpena Pound)


FROM:

OR ON:

The school/preschool will use the students current Health Care Plan unless otherwise instructed.
Has a current Health Care Plan been provided to the school/preschool?

Yes

No

If No, please provide an updated Health Care Plan to the school/preschool on completion of this form.
.
Agreement
I agree to delegate my authority to supervising teachers/instructors. Such supervisors may take whatever disciplinary
action they deem necessary to ensure the safety, well-being and successful conduct of the students as a group and
individually.
In the event of an accident or illness and contact with me being impracticable or impossible, I authorise the teacher-incharge to arrange whatever medical or surgical treatment a registered medical practitioner considers necessary. I will pay
all medical and dental expenses incurred on behalf of my child.
I have also attached additional or updated health care information, including details of any additional health support
he/she requires to undertake the above activities safely. I also consent to my childs doctor or medical specialist being
contacted in an emergency.
The information given is accurate to the best of my knowledge.
Signed:

Date:

Emergency Contacts - Parent/Guardian


NAME

ADDRESS

POSTCODE

HOME TELEPHONE

WORK TELEPHONE

Student Medic Alert Number (If applicable):

ALTERNATIVE TELEPHONE

*Any health care information provided is not intended to prevent your child participating unless specific medical advice warrants exclusion. The health care
information you supply to the school/preschool will be treated confidentially. Such information is sought in order to protect and assist the student so the
activity may be a safe and enjoyable experience. Please contact the teacher-in-charge if you wish to discuss any health care problems.

The DECD CAMPS & EXCURSIONS GUIDELINES FOR SCHOOLS & PRESCHOOLS is available at:
http://www.decd.sa.gov.au/docs/documents/1/CampsandExcursionsGuide.pdf

Flinders View Primary


Flinders View Primary School
School
Valuing Respect, Responsibility, Honesty and
Teamwork
Valuing Respect, Teamwork,
Responsibility and
Honesty

Medical andPhnConsent
Form
86425866
Fax

Principal Anna Nayda


86423406

Section 1: Person Detail


Student Name.

Date of Birth..

Name of School Flinders View Primary School


Emergency Contact Person..

Contact No.

Section 2: Health Support Information


Asthma
Severe Allergy (e.g. bee sting)
Joint disorder
Vision impairment
Ear disorder
Incontinence
Medication usually taken at school
Other (please provide details)
Please complete the following information

Seizures, epilepsy
Diabetes
Heart Disorder
Hearing Impairment
Skin Condition
Swallowing/Choking
Communication difficulties

Have you attached health care details from your childs doctor/treating health
professional? YES/NO
If NO, staff will provide standard supervision for safety and first aid.
If YES, please write down what you have attached and please ensure all relevant
medication is provided

CONFIDENTIAL
To be completed by the Parent/Guardian for students to participate in the excursion to attend the Room 19
Section 3: Consent
I give my consent for my child named above to participate in the Room 19 Wilmington History
Excursion on the 22nd of September 2015.
I understand that school staff will be present and provide supervision for safety.
Parent/Guardian.

Date.

Wilmington History Excursion on the 22nd of September, 2015.


STUDENTS WILL NOT BE PERMITTED TO PARTICIPATE WITHOUT A COMPLETED AND SIGNED CONSENT FORM

Dear Parent and caregivers,

This year Room 19 is going on an excursion to Wilmington. This will occur


on Tuesday the 22nd of September. We will be leaving at 9:30am and
returning at 2:30pm that afternoon.
The class will be visiting the Wilmington Toy Museum and the Wilmington
Puppet Museum. Here we will be looking at and exploring the toys and
puppets which will help us to understand how these items have changed over
time. We will also be looking at the different ways that puppets are
constructed to create movement.
Mostof the cost of the excursion will be subsidised by our class budget.
However, in order to assist with the costs, students attending the excursion
will need to pay $5 each.
This money can be paid directly to the front office and must be paid by
Thursday 17th of September. If you prefer you can organise a payment
plan by seeing Bev in the front office.
You will receive more information regarding the excursion as we draw closer
to the date, but if you have any concerns or questions feel free to come and
talk to me about them.

Thank you,

Sage Othams
Room 19 Class teacher

AN
Principal

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