Dunes Learning Center Adult Participant Form
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 info@duneslearningcenter.org
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Name of School or Group *
Choose one from the list below
Participant First Name *
Participant Last Name *
Birth Date *
MM
/
DD
/
YYYY
Gender *
Street Address *
City *
State *
Postal Code *
E-mail Address *
Home Phone
Work Phone
Mobile Phone *
Emergency Contact *
Emergency Contact: Relationship *
What is the emergency contact's relationship to you?
Emergency Contact Home Phone
Emergency Contact Work Phone
Emergency Contact Mobile Phone *
Health Information
Dietary Restrictions *
IF YES, PLEASE COMPLETE AND RETURN OUR DIETARY RESTRICTION FORM FOUND AT DUNESLEARNINGCENTER.ORG/DOCUMENTS
Dietary Restrictions
Please list food allergies, reactions to food, and treatments used. You may also list any religious or vegetarian restrictions here.
Allergies
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.
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
Are you Hispanic/Latino? (choose only one)
Clear selection
Race
No matter what you selected above, please mark one or more boxes to indicate race.
Clear selection
Permissions
Photo Release
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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.
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