Field Trip Registration Form (Credit Card Deposit)

Registration Form – With Online Payment
Use this form to pay online by credit card or digital wallet. If you’re paying by check, please use this offline registration form instead. We’ll handle the rest—just get your students ready for a fun day of learning at the farm.
Name of School/Program*
Principal/Director*
School Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Desired Field Trip Date(s)*
School/Program Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Teacher/Point of Contact*

First NameLast Name
Email*
example@example.com
Cell Phone for Day of Trip (must be a cell phone)*
Please enter a valid phone number.Format: (000) 000-0000.
Age/Grade Level(s) Participating (Please confirm attendance if more than one date is needed)*

Field Trip Attendees*
prevnext( X )
Total Number of Students
We understand changing enrollment numbers for the day of the trip will be adjusted. $10 per Student

$10 Number of Students Attending
Item subtotal:$0.00



Total Number of Teachers, Aides, School Staff
$ Free Number of Teachers, Aides, School Staff:



(Optional) Total Number of Parents/Chaperones (Non-Teaching Staff)
$5 per Parent or Chaperone

$5 Number of Parents/Chaperones:
Item subtotal:$0.00



(Optional) Total Number of Non-Student Children
$10 per child

$10 Number of Non-Student Children:
Item subtotal:$0.00



(Optional) Would you like to extend your trip time from 90 minutes to 2 hours?
Additional $2 per student & parent/chaperone

$2 Number of Students Attending
Item subtotal:$0.00



(Optional) Would you like the use of our picnic tables for a 30 minute lunch after or before your field trip?
Additional $2 per student & parent/chaperone

$2 Quantity
Item subtotal:$0.00



Total

$0.00

Complete Your Form:
Pennsylvania has enacted Act 27 requiring participants in any ‘agritourism’ location to be aware of the following:“AGREEMENT AND WARNING: I understand and acknowledge that, except for limited circumstances listed below, an agritourism activity provider is not liable for any injury to or death of a participant resulting from an agritourism activity. Our school understands the acceptance of all risk of injury, death, property damage and other loss that may result from an agritourism activity. I understand that an agritourism activity provider is not protected from liability if the provider: (1) Performs an act in a grossly negligent manner and causes injury or damages to a participant. (2) Purposefully causes a participant’s injury. (3) Acts or fails to act in a way that constitutes criminal conduct. (4) Recklessly fails to warn or guard against a dangerous condition that causes injury or damages to a participant. A dangerous condition is a condition that creates an imminent and substantial risk of injury or damages to a participant.”If you have any questions on the above wording, please let us know.*

By checking this box and signing below, our school agrees to the extended Terms & Conditions provided. Our school assumes full responsibility for its students, teachers, chaperones, bus drivers, and all others in attendance with the group and will not hold Valley Fruits & Veggies liable in any manner. Bus/van drivers & transportation vehicles MUST remain at Valley Fruits & Veggies during the scheduled trip.
Signature*

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A 30% Partial Deposit is Required*
Complete payment is to be made within 15 days to hold your day and time.

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

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Registration Form – With Online Payment

Complete Your Form: