PBSD 2149 (Rev. 7/16/2018)
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Instructions - PBSD 2149 Field Trip/Activity Roster - Page 1
Place a check in this column if the person named is a student.
Place a check in this column if the person named is an employee chaperone.
Place a check in this column if the person named is someone other than a student or chaperone.
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Column A
Column B
Column D
Fill in the demographic information at the top of the form.1
Complete the Financial Summary of the Trip as follows:
Total Trip Cost - the total cost of the trip for all participants - airfare, hotels, and any other fees that will be
paid by the school as part of the cost of the field trip.
Total Payments Received - the form will automatically total the payments listed on pages 2-7 if the form is
completed online - this is the total of Column F from pages 2-7 of the form.
Funds Generated from Fundraising, Donations, and Other Revenues - enter any additional funds that are
available to cover trip costs and provide documentation of those amounts.
Funding Status - this will be calculated on the form - a positive balance indicates a surplus and a negative balance
indicates a deficit. If there is a deficit balance, attach a plan explaining how the sponsor intends to cover the
deficit prior to the close of the school year. The Comments section may also be used to provide this information.
3 Use the Comments section to explain how a deficit will be covered or to provide any additional information that
will be helpful to the approving official.
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5
Sign the form and obtain the principal's approval.
For out-of-state or overseas field trips only, obtain the approval of the Instructional/Regional Superintendent at least two
weeks prior to the departure date. If there is a competition or other event where two weeks' notice is not possible, note
that fact in the Comments section and route the form to the Instructional/Regional Superintendent for approval as soon as the
travel arrangements have been finalized.
Use pages 2-7 to list each of the field trip participants. When printing the form, specify the beginning and ending
page numbers - print all page numbers that apply to this field trip.
Instructions - PBSD 2149 Field Trip/Activity Roster - Pages 2-7
Enter the name of each person who will be participating in the field trip.
Enter the actual payment received from each participant in the Payment Received column.
(1) If the person listed made a whole or partial payment, list the amount paid. Fee waivers for
students traveling out-of-state must be documented by completing a Field Trip Payment Waiver form,
PBSD 2471. If a full waiver is granted to a student, enter WAIVER in this column.
(2) If the chaperone received a fee waiver as a result of complimentary tickets provided by the travel
agency, enter COMP as the amount paid. Complimentary travel awarded by the travel agency
may only be used by official chaperones or they may be used to reduce the per-student cost of the trip.
Column E
Column F
Column G
Column H
Column I
Column J
Column K
NOTE:
Place a check in this column if the person named has provided a signed permission slip.
Place a check mark in this column if the person named will be attending the field trip.
Place a check mark in this column if the person named will not be attending the field trip.
Place a check mark in this column if the person named is unable to attend due to an absence.
If the student is not attending but is present in school, enter the name of the teacher who will be responsible
for supervising the student while the rest of the class is on the field trip.
Columns H - K may only be applicable for local trips that occur during the regular school day.
Column L (1) If any of the non-student participants are related to any other person listed, identify those relationships.
For example, if Mary Smith is serving as a chaperone and her son, David Smith, is also attending, next to Mary's
name enter "Mother - David Smith" to cross-reference and disclose the family relationship.
(2) If any participants are related to anyone who will derive a financial benefit from the field trip
(e.g., travel agent) disclose that relationship. An example would be entering "Father Owns Travel Agency"
in the event one of the participants is the son or daughter of the travel agency that made the trip arrangements.
(3) District employees are required to review Policy 3.02, Code of Ethics, for further guidance regarding
possible conflicts of interest that may arise due to outside business affiliations.
All collections from students must conform to the guidelines outlined in School Board Policy 2.21
School Requests of Payments from Students
THE SCHOOL DISTRICT OF PALM BEACH COUNTY
Field Trip / Activity Roster
Column C Place a check in this column if the person named is a volunteer chaperone.
