Dunes Learning Center Student Participant Form 2025-2026 School Year

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Please complete this form for each student attending a program at Dunes Learning Center overnight programs. If you have any questions, please call Dunes Learning Center at (219) 395-9555 or email info@duneslearningcenter.org.

Name of School or Group

(Select one from list below)

Homeroom Teacher *

Student First Name *

Student Last Name *

Date of Birth for Student *

YYYY

Gender (for the purposes of dormitory lodging) *

Male

Female

Non-binary

Other

Parent/Guardian Contact Information

Parent/Guardian First Name *

Parent/Guardian Last Name *

Street Address *

City *

State *

Zip/Postal Code *

E-mail Address *

Mobile Phone *

Secondary Phone (home or work)

Emergency Contact *

If the primary parent/guardian cannot be reached, who should we contact?

Emergency Contact: Relationship *

What is the emergency contact's relationship to your student?

Emergency Contact Mobile Phone *

Emergency Contact Secondary Phone (home or work)

Student Health Information

Student Health: Dietary Restrictions *

If YES, please complete and return our dietary restriction form found at duneslearningcenter.org/dietary

Yes

Student Health: Dietary Restrictions

Please list food allergies, reactions to food, and treatments used. You may also list any religious or vegetarian restrictions here.

Student Health: Allergies

Includes insect bites, medications, hay fever, asthma, etc. Please include the severity and treatment.

Student Health: Conditions

Please list any serious or chronic medical conditions or recent illness/surgery (include dates). Please describe any diagnosed behavioral or functional learning needs as well as sleep disturbances or concerns.

Student Health: Exempted Activities

Please list any activities from which the camper should be exempted (not participate) for health reasons.

Student Health: Mental Health

Has the student required mental health/psychiatric counseling or hospitalization? Please include diagnosis and dates.

Student Health: Medications

Please list any medications that will be taken while at camp, with dosage schedule.

I attest that all immunizations required for school are up to date. *

Yes

Required

Date of most recent tetanus shot? (Td, Tdap, DTaP, etc.)

YYYY

What makes your student shine? Is there anything else we should know?

Demographic Data

Our funders would like to know more about the students that we serve. Please help us by providing answers to the questions below.

Ethnicity

Is the student Hispanic/Latino? (choose only one)

No, not Hispanic/Latino

Yes, Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race)

Clear selection

Race

No matter what you selected above, please select one or more boxes to indicate the student’s race.

American Indian or Alaska Native (A person having origins in any of the original peoples of North and South America, including Central America, and who maintains a tribal affiliation or community attachment)

Asian (A person having origins in any of the peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam)

Black or African American (A person having origins in any of the Black racial groups of Africa)

Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands)

White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa)

Multiracial

Permissions

Photo Release *

I hereby grant Dunes Learning Center and their involved partners, including the National Park Service and the National Park Foundation, the right to photograph my child and use those images for publication purposes, whether electronic, print, digital or video.

Please do not photograph my child.

PARENT/GUARDIAN MEDICAL AUTHORIZATION, RELEASE STATEMENT AND HEALTH WAIVER FOR STUDENTS UNDER 18 YEARS OLD (agreement, indemnification, and assumption of risk)

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 for my student’s participation. I certify that the participant is fully capable (except where noted) of participating in Dunes Learning Center (DLC) activities and does so voluntarily. 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 and the participant during the entire period of participation in DLC activities.

I hereby give permission to medical personnel selected by school or DLC staff to order X-rays, routine tests, necessary treatment and transportation. I hereby give permission to the physician selected by the group, school or DLC staff to secure and administer treatment; including hospitalization, injection, anesthesia, surgery, and transfusion. I agree to pay all costs associated with that treatment and transportation. To ensure safety and wellbeing, I hereby give permission for DLC to provide local transportation. It is expressly understood and agreed that DLC shall not be responsible or legally liable for any losses of personal property, communicable diseases, or for any bodily injuries, or the results thereof, incurred and suffered by the participant or in connection with any activities or programs, unless such loss or injury results directly from the negligent or willful act of an employee of DLC acting within the scope of his/her employment.

DLC educational and/or adventure and recreation activities on or off DLC premises (which may be scheduled or unscheduled, supervised or unsupervised, or occur during free time), may include, but are not limited to: hiking; backpacking; camping; wading; snowshoeing; service and research projects; and wildlife/nature observation. I acknowledge that the inherent and other risks, hazards and dangers of these activities can cause injury, damage, or other loss to participants or others.

Health Policies and procedures for camp operations are based on guidelines put forth by the Center for Disease Control (CDC), the Indiana Department of Health, Porter County Health Department, and the American Camp Association. Dunes Learning Center in no way warrants that a communicable disease or infection will not occur through participation in our programs or accessing DLC facilities. Dunes Learning Center will work closely with teachers and schools to meet any necessary health and safety protocols. Activities will take place outdoors as much as possible (except during inclement weather).

We ask that you help us protect and maintain the health and safety of everyone at DLC by agreeing to the following procedures:

The participant will not attend if they have a fever, digestive issues, respiratory or unexplained skin issues. The participant will not participate if they have taken any medication for the purpose of reducing fever such as acetaminophen or ibuprofen in the past 24 hours. Symptoms include fever of 100.4° or higher, shortness of breath, persistent cough, sore throat, headache, diarrhea, nausea, vomiting, abdominal pain, and/or new loss of taste or smell. Skin issues may include unexplained rash, bruising or bleeding, or inflamed eyes.

I agree that I (or my emergency contact) will be available to take the participant home from Dunes Learning Center if the participant exhibits signs of illness and that I will follow instructions provided by DLC staff upon arrival.

PARENT/GUARDIAN MEDICAL AUTHORIZATION, RELEASE STATEMENT AND HEALTH WAIVER FOR STUDENTS UNDER 18 YEARS OLD (agreement, indemnification, and assumption of risk) *

I agree

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. *

Non-Discrimination Statement

Dunes Learning Center is an equal opportunity provider and does not discriminate.

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