Dunes Learning Center Adult Participant Form 2019-20
Each adult participating in a Dunes Learning Center program must complete and submit this form. If you have any questions, or need assistance, please phone Dunes Learning Center at (219)395-9555 or email
Name of School or Group
Choose one from the list below
Liberty Elementary 1, August 29
Liberty Elementary 2, September 3
Jackson Elementary, September 5
Wilbur Wright 8th Grade, September 6
Yost, September 9
Wilbur Wright 7th Grade, September 10
HAST, September 11
Brummitt Elementary 1, September 16
New Prairie Middle School 1, September 17
Brummitt Elementary 2, September 18
New Prairie Middle School 2, September 19
Highland HS, September 23
Sacred Heart Academy, September 23
Francis Parker, September 25
Bailly Elementary 1, September 30
Coonley Elementary 1, October 2
Lewis Cass, October 7
Frank Hammond 1, October 10
Simatovich, October 14
Nature Exploration Academy, October 14
Frank Hammond, 2, October 17
Bailly Elementary 2, October 21
Union Center, October 23
Coonley Elementary 2, October 28
Baker Demonstration, November 4
Burnett Creek 2, November 5
Clark Natural Helpers, November 14
Other - Name the date
Our Lady of Mount Carmel Academy, November 22
Participant First Name
Participant Last Name
Emergency Contact: Relationship
What is the emergency contact's relationship to you?
Emergency Contact Home Phone
Emergency Contact Work Phone
Emergency Contact Mobile Phone
If YES, please complete and return our dietary restriction form found at
Please list food allergies, reactions to food, and treatments used. You may also list any religious or vegetarian restrictions here.
Includes insect bites, medications, hay fever, asthma, etc. Please include the severity and treatment.
Health Concerns & Medications
Please list any medications and relevant health history.
Please list any activities from which you should be exempted for health reasons
Date of most recent tetanus shot
Our funders would like to know more about the students that we serve. Please help us by providing answers to the questions below.
Are you 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 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)
I hereby grant Dunes Learning Center the right to photograph me and use those images for publication purposes, whether electronic, print, digital or video.
Please do not photograph me.
MEDICAL AUTHORIZATION AND RELEASE STATEMENT (agreement, indemnification, and assumption of risk)
I hereby give permission to medical personnel selected by school or Dunes Learning Center (DLC) staff to order X-rays, routine tests, necessary treatment and transportation. I hereby give permission to the physician selected by 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. It is expressly understood and agreed that DLC shall not be responsible or legally liable for any losses of personnel property or for any bodily injuries, or the results thereof, incurred and suffered by the applicant 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; swimming; cross-country skiing; snowshoeing; service and research projects; and wildlife and nature observation. I acknowledge that the inherent and other risks, hazards and dangers of these activities can cause injury, damage, or other loss to participant or others.
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.
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.
Never submit passwords through Google Forms.
This form was created inside of Dunes Learning Center.
Terms of Service