Form M – Field Trip Attendance Application

Completion of this form is required in order to attend a school sponsored field trip if you are not

currently a School Board-approved volunteer.

By completing this application, I agree that I will attend/plan to attend one (or more) field trips during the

school year. I understand that I will be attending an activity of the Santa Rosa County

School System without compensation and without any rights to health benefits in case of illness or injury.

I understand that I need to renew this application annually. As a field trip attendee, I agree to follow the

guidelines listed below:

1. I will not assume responsibility for any children or youth that are not members of my family.

2. I understand that I am not allowed to include any other children who are not members of this

class or group in school sponsored field trips.

3. I will not participate in any risky or inappropriate behaviors during the field trip event(s)

(i.e., smoking tobacco, using drugs or alcohol that may influence my behavior or interfere with

the event).

4. I will report any student discipline issues to the adult in charge of the activity.

5. I will report to the event coordination site on time and leave promptly after the conclusion of the

event.

School Name

Work Phone: Cellphone:

Date of Application:

Name (please print):

Date of Birth:

Address:

Email:

Health: (any physical limitations)

Affidavit of Character

The following questions must be answered truthfully. A “yes” answer will not necessarily disqualify you

from consideration. However, the Santa Rosa County School Board reserves the right to request that you

be fingerprinted at your own expense prior to participation in a field trip event.

☐Yes ☐No 1. Have you ever been convicted of an offense other than a minor traffic violation?

(DUI and DWI convictions are not minor and must be reported.)

☐Yes ☐No 2. Have you ever been found guilty of a criminal offense?

☐Yes ☐No 3. Have you ever entered a nolo contendere or no contest plea?

☐Yes ☐No 4. Have you ever had adjudication withheld in a criminal offense?

☐Yes ☐No 5. Have you ever entered a pre-trial intervention program for a misdemeanor or

felony charge?

☐Yes ☐No 6. Are there criminal charges currently pending against you?

Santa Rosa County District Schools

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☐Yes ☐No 7. Have you ever been placed on court-ordered probation, imprisoned, or jailed in a

criminal proceeding?

☐Yes ☐No 8. Have you ever failed to appear in court or forfeited bond in a criminal proceeding?

☐Yes ☐No 9. Have you ever been confirmed as a child abuser by the Department of Children and

Families or a similar agency in Florida or another state?

If you answered “yes” to any of the above questions, you must give a detailed explanation in the

following space or on another page if extra space is needed:

ARREST

Where Arrested:

Arresting Agency:

Date of Arrest:

Offense:

By signing this document, I certify that all information contained herein is true and accurate. My signature

further certifies that there is no falsification of any information, omission of any information requested,

or any misrepresentation of information requested. I also understand that if I am requested to complete a

full background check prior to participation, I will assume the cost of the fingerprinting and my

fingerprints may be submitted to the Florida Department of Law Enforcement and Federal Bureau of

Investigation for a complete criminal history background check.

By my signature, I certify that I know, understand, and agree that any false statement or omission of

information requested will result in my name being removed from the approved field trip participant list

for this Santa Rosa County School.

Signature of Parent/Guardian Date

You will be notified by the school if your application has been denied.

Status: ☐Clear ☐Not Clear

District Processing Information

This request does not require school board approval. Records of completed applications should be

maintained at the school site for five years after the field trip events.

Date of Dru Sjodin National Sex Offender Public Registry Check

Person Completing Check

Principal Decision

☐Approved as submitted for field trip(s) attendance.

☐Not approved

Notes:

Santa Rosa County District Schools

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