Outreach Permission Form
Please complete the form below so that your student can participate in Dunes Learning Center Outreach activities.
Programs covered by this permission form include (but are not limited to) Mighty Acorns, Citizen Science, CIMBY, and Chellberg Farm. If you have any questions, please contact Outreach Education Coordinator, Alisha Zick at
Teacher Last Name
Wallace Aylesworth Elementary School
Benjamin Banneker Achievement Center
Bishop Noll High School
Joseph L Block Junior High School
Central Elementary School
Clark Middle School
Crisman Elementary School
Charter School of the Dunes
Chesterton High School
Discovery Charter School
East Chicago High School
Gary Westside High School
George Rogers Clark Middle School
George Rogers Clark High School
Growing Kids Learning Center
Heavilin Elementary School
Hobart High School
Hobart Middle School
Jefferson Elementary School
Joan Martin Elementary School
Ethel R Jones Elementary School
Rowena Kyle Elementary School
Lake Central High School
Lake Hills Elementary School
LaPorte High School
Liberty Elementary School
Frankie W McCullough Academy
William McKinley Elementary School
Merrillville High School
Michigan City High School
Munster High School
Nature Exploration Academy
New Prairie Middle School
George L Myers Elementary School
Frank O'Bannon Elementary School
Paul Saylor Elementary School
Plainfield High School
Portage High School
Prairie View Elementary
Ridge View Elementary School
Saint May's College Early Childhood Development Center
Social & Learning Institute
South Haven Elementary School
St.Patrick's Catholic School
Valparaiso High School
Lew Wallace Elementary School
Washington Elementary School
Westville High School
Whiting Middle School
Wilbur Wright Middle School
Student Name (first and last)
Parent/Guardian First Name
Parent/Guardian Last Name
Please list any allergies, medical conditions, diagnosed behavioral or learning disabilities that we should know about.
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.
Please do not photograph my child.
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 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.
Our funders would like to know more about the students that we serve. Please help us by providing answers to the questions below.
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)
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.
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