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 azick@duneslearningcenter.org or (219)395-9555.
Teacher Last Name
Your answer
School Name *
Grade Level *
Birthdate *
MM
/
DD
/
YYYY
Student Name (first and last) *
Your answer
Parent/Guardian First Name *
Your answer
Parent/Guardian Last Name *
Your answer
Phone Number *
Your answer
Email address *
Your answer
Student Health
Please list any allergies, medical conditions, diagnosed behavioral or learning disabilities that we should know about.
Your answer
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 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.
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)
Race
No matter what you selected above, please mark one or more boxes to indicate the student’s race.
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
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