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
Name of School or Group
Choose one from the list below
Brummitt Elementary , January 9
Yost Elementary 1, January 10
Central Elementary 1, January 15
Central Elementary 2, January 17
St. Thomas More, January 18
Jackson Elementary, January 29
Skinner North, January 30
Peirce 1, February 14
Gavit Natural Helpers, February 21
Clifford Pierce- Green Team, February 25
Clifford Pierce- Red Team, February 26
Our Lady of Mount Carmel Academy, February 28
Peirce 2, March 5
Clark Natural Helpers, March 7
Clifford Pierce Orange Team, March 11
Clifford Pierce- Silver Team, March 12
Lincoln Elementary, March 13
McKinnley Elementary, March 13
Marian Catholic, March 18
Charter School of the Dunes, March 20
Chicago Academy, March 27
Johnston Elementary, April 2
Wea Ridge 1, April 8
Wea Ridge 2, April 9
St. Louis de Montfort, April 10
Discovery Charter, April 15
Harmony School, April 22
Quest Academy, April 22
Oscar Mayer, April 24
Forest Ridge, April 29
Edgebrook Elementary, May 1
Galileo, May 6
Inter-American Magnet, May 13
Banneker @ Marquette 1, May 15
Banneker @ Marquette 2, May 20
Nativity, May 22
St. Paul Catholic, May 22
Disney Magnet, May 28
Student First Name
Student Last Name
Parent/Guardian Contact Information
Parent/Guardian First Name
Parent/Guardian Last Name
If the primary parent/guardian cannot be reached, who should we contact?
Emergency Contact: Relationship
What is the emergency contact's relationship to you or your child?
Emergency Contact Home Phone
Emergency Contact Work Phone
Emergency Contact Mobile Phone
Student Health Information
Student Health: Dietary Restrictions
If YES, please complete and return our dietary restriction form found at
Student Health: Dietary Restrictions
Please list food allergies, reactions to food, and treatments used. You may also list any religious or vegetarian restrictions here.
Student Health: Allergies
Includes insect bites, medications, hay fever, asthma, etc. Please include the severity and treatment.
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.
Student Health: Exempted Activities
Please list any activities from which the camper should be exempted for health reasons
Student Health: Psychiatric
Has the student required psychiatric counseling or hospitalization? Please include diagnosis and dates.
Student Health: Medications
Please list any medications that will be taken while at camp, with dosage schedule.
I attest that all immunizations required for school are up to date
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.
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)
I hereby grant Dunes Learning Center the right to photograph my child and use those images for publication purposes, whether electronic, print, digital or video.
Please do not photograph my child.
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.
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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