Dunes Learning Center Student Participant Form

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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

Student First Name *

Student Last Name *

Birth Date *

YYYY

Gender *

Male

Female

Parent/Guardian Contact Information

Parent/Guardian First Name *

Parent/Guardian Last Name *

Street Address *

City *

State *

Postal Code *

E-mail Address *

Home Phone

Work Phone

Mobile Phone *

Emergency Contact *

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 duneslearningcenter.org/dietary

Yes

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 *

Yes

Required

Date of most recent tetanus shot

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)

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)

Clear selection

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)

Permissions

Photo Release *

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.

I agree

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. *

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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