Activity Release Form 2022-2023

Brookhaven Treatment and Learning Center 2022-2023

School Year Activity Release Form
Child's Name *

First NameLast Name
Brookhaven Treatment and Learning Center (“Brookhaven”) regularly

offers the following activities for clients in our care. These include but

not limited to: arts and crafts, fishing, land sports, outdoor living skills,

rocketry, swimming, woodworking, as well as other activities. The

walking trips listed below will be completed off of the Brookhaven

campus, and will include but are not always limited to the below

locations. For trips requiring students to be transported off of the

Brookhaven campus and further than walking distance, a separate

permission form will be sent to parents/guardians.

I hereby give notice to Brookhaven that my child can participate inthe following specific activities:*

Walks on nature trails around Chelsea VillageOrange County Sheriffs Department walking tripsVisiting Riverbend Nursing Home: We will be walking to theRiverbend Residential Care Facility (for elderly individuals) to visit theirresidents.Chelsea Animal HospitalChelsea Fire StationChelsea Town Hall Building (Town Clerk Office and Library)Mascoma Savings Bank Chelsea LocationChelsea Post OfficeChelsea Public SchoolOther locations NOT within walking distance of Brookhaven campus. These may include, but are not limited to, VTC Shape Pool in Randolph, VT, trips to Lebanon, NH/Norwich,VT-area (Montshire Museum, HOP at Dartmouth College campus).
At times we do offer students to attend learning experiences and

rewards off campus. These may include but are not limited to VTC

Shape Pool in Randolph, VT, trips to Lebanon, NH/Norwich,VT

area (Montshire Museum, HOP at Dartmouth College campus).

By signing, you are providing permission for your student to

participate in any off-campus activities/rewards provided by Brookhaven Treatment and Learning Center. Your student will be

with Brookhaven staff, and potentially transported by Brookhaven

staff.
Permission for Enrollment and Release of Brookhaven from

Liability

As parent or legal guardian of Participant, I verify that Participant is in

good physical condition and is physically capable of participating in the

activities offered by Brookhaven. I have reviewed the Brookhaven

walking trips and acknowledge that I understand the activities offered by

Brookhaven can be hazardous because of the risk of injury inherent in

such activities. Nonetheless, as guardian of said child, I consent to his

participation in above checked field trips as well as on and off campus

activities during the 2019-2020 Brookhaven Treatment and Learning

Center school year. I agree to indemnify and hold harmless, Brookhaven

Treatment and Learning Center, and its employees, in the event of any

injury and/or death from said child's participation; whether on site, or off

site.
Parent/Guardian Signature*

Clear
Parent/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Date*

MonthDayYear
Date
Should be Empty:

Brookhaven Treatment and Learning Center 2022-2023