FIELD TRIP CONSENT AND RELEASE FORM ACTIVITY/TRIP NAME: Silk Road Exhibit at the Natural History Museum DESCRIPTION, LOCATION & METHOD OF TRANSPORTATION: Students will take the subway to visit the Silk Road exhibit at the Natural History Museum. The trip will be during regular school hours. Please be advised that students must bring a snack with them to eat, since we will be eating lunch at a later time. ____________________________________________________________________________________ DATE(S) OF TRIP: Thursday, February 11, 2010 I, ________________________, am the parent or legal guardian of the minor child/children listed below. I give my permission for my child/children to participate in the activity or trip listed above. I understand that participation in Brooklyn Prospect Charter School includes physical education as well as classroom activities and off-site trips. I have read the information provided, if any, about the activity/trip identified above. ACKNOWLEDGEMENT OF RISKS AND ASSUMPTION OF RISK AND RESPONSIBILITY (Whenever the word child is used in this form, the term refers to all of the students identified at the bottom. I understand that in signing this Field Trip Consent and Release Form I am consenting to the participation in trips and or activities for all of the students named above. If I am a student over the age of 18, I am signing this form on my own behalf.) ACKNOWLEDGMENT OF RISKS: I recognize the fact that there are risks, foreseeable and unforeseeable, in the activities described above and in all trips and all travel related activities. I realize that my child could suffer death, injury or illness and could require medical attention. I acknowledge these risks and confirm that my child’s participation in this activity or trip is voluntary. I consent to my child’s participation in this trip and all activities except for the following: _________________________________________________. EXPRESS ASSUMPTION OF RISK AND RESPONSIBILITY: My child’s participation in the above named activity or trip is voluntary and I assume all risks and full responsibility, on behalf of all parties including myself, my child, my child’s other guardians, and my child’s heirs and assigns, for (a) any and all losses incurred as a direct or indirect result of personal injury, accident, illness, or death, and (b) any and all damage to or loss of personal property arising out of, relating to, or in connection with any the above-named activities or trips or any trip-related activity. WAIVER AND RELEASE FROM LIABILITY: On behalf of my child, myself, my child’s other guardians and my child’s heirs and assigns, I hereby assume all risks and waive, release, and forever discharge Brooklyn Prospect Charter School and its trustees, employees, agents and its related entities from any and all liability, actions, and damages of whatever kind, including, without limitation, general, special, compensatory and punitive damages, for personal injury, property damage, negligence or wrongful death arising out of, relating to, or occasioned wholly or in part by the activity or trip or any trip-related activities. MEDICAL AUTHORIZATION: I hereby authorize any medical treatment deemed necessary while my child is participating in any activities referred to above. In the event of illness or injury, I authorize Brooklyn Prospect Charter School and each of its employees, representatives and agents to take such measures as are available and appropriate in the judgment of the persons taking such measures, and I consent to emergency medical treatment and care which may be deemed necessary to be rendered. Brooklyn Prospect Charter School will make reasonable efforts to reach me in the event of an emergency requiring medical care. I HAVE READ THIS AGREEMENT AND UNDERSTAND ITS CONTENTS. I ASSUME THE AFOREMENTIONED RISKS, AND AGREE TO THE WAIVER OF LIABILITY AND TO HOLD BROOKLYN PROSPECT CHARTER SCHOOL HARMLESS. Student Name(s) (Print): _________________________________________________________________ Signature of Parent/Legal Guardian Date (Or Signature of Student if Over 18) (Print Name) Emergency Telephone Lunch Lunch will be eaten at school once we return from the field trip. Because it is after our normal cafeteria time, students who usually buy a lunch will be provided with a bag lunch.* Please check one: My child will bring his/her own lunch to eat at school_________ My child will need a bag lunch to eat at school___________ *Students must bring an easy to eat and healthy snack with them on the fieldtrip, since we will be eating lunch after our normal cafeteria time. 153 35TH STREET, BROOKLYN NY 11232 PHONE: 718-965-7950