Orlando Science Center Field Trip

Complete this form and submit payment for your child to attend the field trip.

February 8th, 2023

Student Name(Required)

First Last

The undersigned, who is the parent/guardian of named above, a minor (hereinafter referred to as “Student”), on behalf of himself and student, their personal representative, assigns, heirs and next of kin, request Student is permitted to participate in the aforementioned event:

Acknowledgements(Required)

Hereby releases, waives, discharges and covenants not to sue, Pace Brantley School, their officers, employees and agents, all for purposes herein referred to as Releases, from all liability to the undersigned and Student, their personal representatives, assigns heirs and next of kin, for all loss or damage, and/or claims, demands, causes of actions or suit of any kind therefore, particularly on account of injury to the person or property or resulting in the death of Student, whether caused by the negligence of Releases or otherwise, while Student is a participant in the aforementioned event;

Hereby agrees to indemnify and save and hold harmless the Releases and each of them from any loss, liability, damage, or cost they may incur while Student is a participant in the aforementioned event, whether caused by the negligence of the Releases or otherwise;

Hereby assumes full responsibility for and risk of bodily injury, death or property damage due to the negligence of Releases or otherwise while Student is a participant in the aforementioned event;

Hereby agrees that if any portion of the Agreement is held invalid, that the balance shall, notwithstanding, continue in full legal force and effect.

Typing your name in this box serves as your official signature on the Field Trip Permission Form(Required)

First and Last Name

Medical Information: In the event Student becomes ill, I authorize the faculty or chaperones to obtain medical attention at a physician’s office or hospital. Student is covered by the following medical insurance:

Insurance Company Name(Required)

Group Number(Required)

Allergies(Required)

If none, type none

Chronic/Acute Illnesses(Required)

If none, type none

I UNDERSTAND THAT EVERY EFFORT WILL BE MADE TO REACH ME BEFORE MEDICAL PERMISSION IS GIVEN TO TREAT MY CHILD.

Home Phone

Parent/Guardian Work Number(Required)

Parent/Guardian Work Number

Parent/Guardian Cellphone Number(Required)

Parent/Guardian Cellphone Number

Typing your name in this box serves as your official signature confirming medical information.(Required)

First and Last Name

Email(Required)

Field Trip Fee (Required)

Price: $35.00

Total

Credit Card

Card Details

Cardholder Name