Date:_________________

To:(Dept. Head, Dean of College, Associate Dean)_____________________________________

Class__________________________   Instructor_______________________________

No. of Students Involved _________                Co-ed     Male     Female

Destination & Nature of Proposed Trip ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Date & Time of Departure _____________  Date & Time of Return _____________

Estimated No. of Classes Missed by Students _______________________________

Names of Chaperones

_________________________________________________

                                              _________________________________________________

                                              _________________________________________________

Mode of Transportation ____________________________________________________

If Overnight, Type of Housing _____________________________________________

Estimated Expense per Student _____________________________________________
 

                                                   ________________________
                                                   Signature of Instructor

Approval               Disapproval

________               __________                   _______________________
                                                     Head of the Department

________               __________                   _______________________
                                                      Dean of the College

Copy to the Dean of Student Life