Transportation/Trip Request

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Please complete and submit this form at least two weeks in advance of your request.
Upon submission, your form will automatically be emailed to your supervisor for approval, and then on to Marion School District Transportation Coordinator, Tracy Schwartz.

Email *

Your Supervisor's Email Address *

Person/Department Responsible for the Trip *

Destination with address *

Type of Activity *

Field Trip

Professional Conference

Professional Meeting

Sporting Event

Student Conference

Other:

Trip Date *

YYYY

Grade Level *

Number of Students *

Number of Adults *

Place of Departure *

Front of High School

Front of Elementary School

District Office

Fieldhouse

Bus Garage

Other:

Departure Date & Time *

Very Important: MUST be before the return time!!

YYYY

Time

Return Date & Time *

Very Important: MUST be after the departure time!!

YYYY

Time

If driving, date the gas card would be picked up

Pick up gas card from your primary building’s office; return the gas card and receipt to the same office promptly upon returning to the district. You no longer need a key for the bus garage. Your employee badge will grant you access to the central access door. The light switches are by the central access door and the west access door.

YYYY

Type of Vehicle *

How does the trip relate to the class activity? Explain pre- and post- activities planned to make use of the information gained from the trip. *

List any students with known health concerns

List and explain any special arrangements that are necessary, including student name, concern and provision.

Do you need extra transportation for equipment? *

Yes

Are there any students needing medication? *

Yes

List the name and medical instructions for any students requiring medication or medical care.

Are there any adults able to administer first aid or emergency care? *

Yes

List emergency help available at destination *

Nearest Hospital/Emergency Medical Services *

Appleton Medical Center, Phone 920-288-8000

Ascension NE Wisconsin St. Elizabeth Hospital, Appleton, Phone 920-738-2000

St. Mary's Hospital, Green Bay, Phone 920-498-4200

St. Vincent Hospital, Green Bay, Phone 920-433-0111

New London Medical Center, New London, Phone 920-531-2000

Shawano Medical Center, Shawano, Phone 715-526-8140

Ascension St. Michael's Hospital, Stevens Point, Phone 715-346-5000

Riverside Hospital, Waupaca, Phone 800-924-4442

Aspirus Hospital, Wausau, Phone 715-847-2121

Other:

Notes/Special Considerations

By typing my name below and submitting this form this form, I agree to:

Follow all state and federal driving laws when using a school vehicle checked out to me, including no use of a cell phone while operating a school-owned vehicle or on school business,
Drive the school vehicle with care & caution,
Fill the van with gas if the trip exceeds 15 miles,
Turn in all required documentation to the office after my trip,
Remove any garbage and personal items left in the van by students or myself.

Electronic Signature *

Signature Date *

YYYY

Submit

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