Watershed Outreach Permission Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please complete the form below so that your student can participate in Dunes Learning Center Outreach activities with their classmates and teachers. Dunes To You programs covered by this permission form include (but are not limited to) Nature Navigators, Mighty Acorns, Citizen Science, CIMBY, and Chellberg Farm, as well as Wilderness Inquiry Canoemobile activities. If you have any questions, please contact Outreach Education Coordinator, Alisha Zick at azick@duneslearningcenter.org or (219)395-9555.

Teacher Last Name

School Name *

Grade Level *

2nd

3rd

4th

5th

6th

7th

8th

9th

High School

Other:

Birthdate *

YYYY

Student Name (first and last) *

Parent/Guardian First Name *

Parent/Guardian Last Name *

Phone Number *

Email address *

Student Health

Please list any allergies, medical conditions, diagnosed behavioral or learning disabilities that we should know about.

Have you had a seizure or blackout in the last 6 months? *

Yes

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 the student is fully capable of participating in Dunes Learning Center (DLC) activities and does 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 hereby grant Dunes Learning Center the right to photograph my child and use those images for publication purposes, whether electronic, print, digital or electronic. 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.

I agree

Wilderness Inquiry Agreement of Participation and Release of Liability *

I certify that the above information is true, accurate and complete. I recognize there is a significant element of risk in any adventure activity associated with the outdoors and I voluntarily assume that risk. Knowing the inherent risks and rigors involved, I certify that I am fully capable of participating in the Wilderness Inquiry (WI) activities and that I wish to do so as a voluntary participant. While participating in kayak and canoe activities, WI will provide a Coast Guard approved Personal Flotation Device (PFD) of the proper size and I agree to wear the properly fitted, serviceable PFD at all times when the vessel is in motion. In consideration of WI providing the Activities, I hereby release any claims for personal injury or property damage against WI (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 WI. This release of liability may not apply to any incidents occurring on lands administered by the National Park Service. I give permission to WI and involved program partners to use photographs and video for promotional purposes. 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 Wilderness Inquiry activities. This agreement is governed by the laws of the State of Minnesota without applying its choice of law provisions. If any minor children will be accompanying me, I make the same certification and provide the same release on their behalf. If I am a minor, by signing below my parent or legal guardian makes this certification and provides this release on my behalf.

I agree

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 mark 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)

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. *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Dunes Learning Center.

Does this form look suspicious? Report

Forms