Dunes Learning Center Student Participant Form
Please complete this form for each student attending Dunes Learning Center. If you have any questions, please phone Dunes Learning Center at (219)395-9555 or email info@duneslearningcenter.org
Name of School or Group *
Choose one from the list below
Homeroom Teacher
Your answer
Student First Name *
Your answer
Student Last Name *
Your answer
Birth Date *
MM
/
DD
/
YYYY
Gender *
Parent/Guardian Contact Information
Parent/Guardian First Name *
Your answer
Parent/Guardian Last Name *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Postal Code *
Your answer
E-mail Address *
Your answer
Home Phone
Your answer
Work Phone
Your answer
Mobile Phone *
Your answer
Emergency Contact *
If the primary parent/guardian cannot be reached, who should we contact?
Your answer
Emergency Contact: Relationship *
What is the emergency contact's relationship to you or your child?
Your answer
Emergency Contact Home Phone
Your answer
Emergency Contact Work Phone
Your answer
Emergency Contact Mobile Phone *
Your answer
Student Health Information
Student Health: Dietary Restrictions *
If YES, please complete and return our dietary restriction form found at duneslearningcenter.org/dietary
Student Health: Dietary Restrictions
Please list food allergies, reactions to food, and treatments used. You may also list any religious or vegetarian restrictions here.
Your answer
Student Health: Allergies
Includes insect bites, medications, hay fever, asthma, etc. Please include the severity and treatment.
Your answer
Student Health: Conditions
Please list any serious or chronic medical conditions or recent illness/surgery (include dates). Please describe any diagnosed behavioral or learning disabilities as well as sleep disturbances or concerns.
Your answer
Student Health: Exempted Activities
Please list any activities from which the camper should be exempted for health reasons
Your answer
Student Health: Psychiatric
Has the student required psychiatric counseling or hospitalization? Please include diagnosis and dates.
Your answer
Student Health: Medications
Please list any medications that will be taken while at camp, with dosage schedule.
Your answer
I attest that all immunizations required for school are up to date *
Required
Date of most recent tetanus shot
MM
/
DD
/
YYYY
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.
Permissions
Photo Release *
PARENT/GUARDIAN MEDICAL AUTHORIZATION AND RELEASE STATEMENT (agreement, indemnification, and assumption of risk) *
The health history is correct so far as I know, and I hereby give permission for my child to participate in all program activities including field trips and transportation to learning sites, except as noted by me and/or an examining physician. I hereby give permission to medical personnel selected by school or DLC staff to order X-rays, routine tests, necessary treatment and transportation for my child. In the event I cannot be reached in an emergency; I hereby give permission to the physician selected by school or DLC staff to secure and administer treatment; including hospitalization, injection, anesthesia, surgery, and transfusion for my child as named above. 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 personal 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. *
Your answer
Non-Discrimination Statement
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.
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