Dunes Learning Center Program Participant Form
Each individual attending a Dunes Learning Center program MUST complete this form. If you have any questions, please phone Dunes Learning Center at (219)395-9555 or email info@duneslearningcenter.org
Name of Program *
Choose one from the list below
First Name *
Your answer
Last Name *
Your answer
Birth Date *
MM
/
DD
/
YYYY
Gender *
Parent/Guardian First Name
If participant is under 18 years old
Your answer
Parent/Guardian Last Name
If participant is under 18 years old
Your answer
Street Address *
Your answer
City *
Your answer
State *
Postal Code *
Your answer
E-mail Address
For participants over 18 years old
Your answer
Mobile Phone
For participants over 18 years old
Your answer
Emergency Contact *
Who should we contact in case of emergency?
Your answer
Emergency Contact: Relationship *
What is the emergency contact's relationship to you or your child?
Your answer
Emergency Contact Home Phone
Your answer
Emergency Contact Work Phone
Your answer
Emergency Contact Mobile Phone *
Your answer
Dietary Restrictions
Please list food allergies, reactions to food, and treatments used. You may also list any religious or vegetarian restrictions here.
Your answer
Allergies
Includes insect bites, medications, hay fever, asthma, etc. Please include the severity and treatment.
Your answer
Conditions
Please list any serious or chronic medical conditions or recent illness/surgery (include dates). Please describe any diagnosed behavioral or learning disabilities as well as sleep disturbances or concerns.
Your answer
Date of most recent tetanus shot
MM
/
DD
/
YYYY
Demographic Data
Our funders would like to know more about who we serve. Please help us by providing answers to the questions below.
Ethnicity
Is the participant Hispanic/Latino? (choose only one)
Race
No matter what you selected above, please mark one or more boxes to indicate the participant’s race.
Permissions
Photo Release *
Dunes Learning Center Agreement of Participation and Release of Liability *
I certify that the above information is true, accurate and complete. I recognize there is an element of risk in any outdoor activity and I voluntarily assume that risk. I certify that I am fully capable of participating in Dunes Learning Center (DLC) activities and do so as a voluntary participant. In consideration of DLC providing the Activities, I hereby release any claims for personal injury or property damage against DLC (and its agents, employees, directors, officers, and volunteers), arising out of ordinary negligence. I also release such claims arising out of any act by anyone not under control of DLC. I have read, understand, and accept the terms and conditions stated herein and acknowledge that this agreement shall be effective and binding upon me during the entire period of participation in Dunes Learning Center activities. If I am a minor, by indicating my agreement below, my parent or legal guardian makes this certification and provides this release on my behalf.
By entering your name below, you are effectively providing your signature, indicating that the information on this form is true and accurate to the best of your knowledge. *
Your answer
Non-Discrimination Statement
Dunes Learning Center is an equal opportunity provider and does not discriminate based on race, color, creed, religion, national origin, ancestry, nationality, alienage or citizenship status, age, sex, sexual orientation, gender identity or expression, marital status, disability, veteran status, or any other protected status under controlling federal, state or local law.
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