2nd Grade Fall Field Trip

Somerset Academy, Inc

Field Trip Permission Form & Release

Your student is scheduled to participate in an activity/event with Somerset Academy, Inc. d/b/a Somerset Academy St. Lucie (“Somerset”). Read this form completely and carefully. This form acknowledges your choice for your student to participate in the Activity. You and your child agree to comply with all requirements, instructions, orders, directives and guidelines of Somerset while participating in the Activity. I understand and agree that unless granted a waiver for early dismissal, that my child will travel to/from Activity with Somerset. If I have been granted a waiver, it is attached as Exhibit A. Activities such as field trips are not mandatory. They are designed to enhance curriculum, to encourage student
participation in extra-curricular activities, and to serve as extensions to the learning taking place in the classroom. This form must be completed and signed by the student’s parent/guardian in order for the student to participate in the “Activity”, described below:

ACTIVITY / DESTINATION:	Brevard Zoo
PLANNED BY:	Heather Lieberman
GRADE:	2nd Grade
DEPARTURE DATE / TIME:	November 14, 2025 @ 8:15 a.m.
RETURN DATE / TIME:	November 14, 2025 @ 5:00 p.m.
LOCATION / ADDRESS:	8225 N Wickham Rd, Melbourne, FL 32940
METHOD OF TRANSPORTATION:	Charter Bus
PURPOSE / NATURE OF THE ACTIVITY:	Students will be able to observe animals in their natural habitat
ACTIVITY WILL BE CHAPERONED BY:	SASL Teachers and staff
# OF CHAPERONES:	1:10
ACTIVITY FEE:	$57.00
DUE BY:	September 29, 2025

LUNCH WILL BE PROVIDED BY:	Venue
YOUR CHILD HAS THE OPTION OF THE FOLLOWING LUNCH OPTIONS:	PBJ Sandwich, Turkey Sandwich, Hot Dog

I understand that my child may not participate in the Activity without paying the Activity Fee in full. I understand that Activity Fees are non-refundable for any reason, including illness, absence or loss of privileges. If I am unable to pay the Activity Fee, where appropriate and to the extent available, my child may have an opportunity to participate in a fund-raising activity or may be directed to other fund sources for assistance. Please note, this is not available for any Activity unrelated to classroom instruction (i.e. grad-night, athletic contests, banquets, etc)*
PARENT/GUARDIAN INITIALS

EMERGENCY CONTACT INFORMATION
NAME OF PARENT/GUARDIAN (FIRST & LAST NAME)*
FULL NAME (FIRST & LAST NAME)
PARENT/GUARDIAN PHONE NUMBER:*
PARENT/GUARDIAN PHONE #
ALTERNATE PHONE NUMBER:*
ALTERNATE # FOR PARENT/GUARDIAN
IN CASE PARENT/GUARDIAN CANNOT BE REACHED PLEASE CONTACT: *
FULL NAME (FIRST & LAST NAME)
RELATIONSHIP TO STUDENT*
PHONE NUMBER*
Please enter a valid phone number.
ALTERNATE PHONE NUMBER*
Please enter a valid phone number.
PHYSICIAN'S NAME*
PHYSICIAN'S PHONE NUMBER:*
Please enter a valid phone number.
INSURANCE POLICY COVERING MY CHILD:*
POLICY #*
LIST ANY MEDICAL CONDITIONS (IF APPLICABLE):
LIST ANY ALLERGIES (IF APPLICABLE)
MY CHILD TAKES THE FOLLOWING MEDICATIONS REGULARLY (DOCUMENTATION ON FILE WITH SCHOOL):
I AUTHORIZE MEDICAL TREATMENT FOR MY CHILD IN THE EVENT OF ACCIDENT OR ILLNESS ON TRIP.*

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Date*

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PLEASE READ AND SIGN ON THE NEXT PAGE
ACTIVITY RELEASE: BY SIGNING THIS FORM, I ACKNOWLEDGE AND FULLY UNDERSTAND, THERE ARE POTENTIAL RISKS AND HAZARDS ASSOCIATED WITH THE ACTIVITY, INCLUDING, BUT NOT LIMITED TO, EXPOSURE TO COVID-19,
ILLNESS, INJURY OR LOSS OF LIFE. DESPITE THE POTENTIAL RISKS AND HAZARDS ASSOCIATED WITH THE ACTIVITY, I WISH TO PROCEED AND GRANT PERMISSION FOR MY CHILD TO PARTICIPATE. I FREELY ACCEPT AND ASSUME ALL RISKS AND HAZARDS THAT MAY ARISE FROM MY CHILD’S PARTICIPATION IN THE ACTIVITY AND WHICH COULD RESULT IN LOSS, PERSONAL INJURY, ILLNESS, DEATH OR PROPERTY DAMAGE, (COLLECTIVELY, AN “ACTIVITY-RELATED INJURY”),
WHETHER CAUSED BY THE NEGLIGENCE OF RELEASEES, AS DEFINED BELOW, OR OTHERWISE.

I, FOR MYSELF, MY ESTATE, HEIRS, ADMINISTRATORS, EXECUTORS, AND ASSIGNS, AND FOR MY CHILD, MY CHILD’S ESTATE, HEIRS, ADMINISTRATORS, EXECUTORS, AND ASSIGNS (COLLECTIVELY, “RELEASORS”) HEREBY RELEASE AND
HOLD HARMLESS SOMERSET, ITS GOVERNING ENTITY, OFFICERS, DIRECTORS, EMPLOYEES, REPRESENTATIVES, CONTRACTORS, SERVICE PROVIDERS, AGENTS AND ASSIGNS (COLLECTIVELY, “RELEASEES”) FROM ANY AND ALL LIABILITY AND RESPONSIBILITY WHATSOEVER, HOWEVER CAUSED, FOR ANY AND ALL DAMAGES, CLAIMS, OR CAUSES OF ACTION THAT RELEASORS MAY HAVE ARISING OUT OF, CONNECTED WITH, OR IN ANY MANNER PERTAINING TO AN ACTIVITY-RELATED INJURY, WHETHER CAUSED BY THE NEGLIGENCE OF RELEASEES OR OTHERWISE, AND AGREE AND COVENANT NOT TO SUE RELEASEES AND TO HOLD EACH HARMLESS FROM ANY SUCH CLAIMS. I FURTHER AGREE TO INDEMNIFY AND HOLD HARMLESS RELEASEES FROM ANY JUDGMENT, SETTLEMENT, LOSS, LIABILITY, DAMAGE, COSTS OR EXPENSES, INCLUDING COURT COSTS AND ATTORNEY FEES AT BOTH THE TRIAL AND APPELLATE LEVELS, THAT MAY BE INCURRED, OR ARISING OUT OF OR IN ANY WAY RELATED TO AN ACTIVITY-RELATED INJURY, OR IN ANY WAY RELATED TO THE ACTIVITY OR MY/MY CHILD’S PARTICIPATION THEREIN, WHETHER CAUSED BY NEGLIGENCE OF
RELEASEES OR OTHERWISE.

I HAVE READ THIS FORM. I UNDERSTAND ITS TERMS ARE CONTRACTUAL AND NOT A MERE RECITAL. I AM GIVING UP SUBSTANTIAL RIGHTS BY SIGNING THIS FORM. THROUGH MY OWN FREE ACT, I VOLUNTARILY AGREE TO BE BOUND BY IT. I UNDERSTAND I HAVE THE RIGHT TO REFUSE TO SIGN THIS FORM AND SOMERSET HAS THE RIGHT TO REFUSE TO ALLOW STUDENT TO PARTICIPATE IF I DO NOT SIGN THIS FORM.
STUDENT FULL NAME (FIRST & LAST NAME)*
STUDENT'S FIRST AND LAST NAME
GRADE*
STUDENT'S DOB *

MonthDayYear
DATE OF BIRTH
STUDENT'S HOMEROOM TEACHER*
STUDENT ID # (CAN BE FOUND ON SKYWARD)*
LUNCH OPTIONS*
PLEASE CHOOSE A LUNCH OPTION:*
PARENT FULL NAME (FIRST & LAST NAME)*
PARENT'S FIRST & LAST NAME
PARENT EMAIL ADDRESS*
example@example.com
PARENT SIGNATURE*

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TODAY'S DATE*

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Somerset Academy, Inc

EMERGENCY CONTACT INFORMATION

PLEASE READ AND SIGN ON THE NEXT PAGE