Dunes Learning Center Program Participant Form

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Each individual attending a Dunes Learning Center program MUST complete this form. If you have any questions, please phone Dunes Learning Center at (219)395-9555 or email info@duneslearningcenter.org

Name of Program *

Choose one from the list below

First Name *

Last Name *

Birth Date *

YYYY

Gender *

Male

Female

Parent/Guardian First Name

If participant is under 18 years old

Parent/Guardian Last Name

If participant is under 18 years old

Street Address *

City *

State *

Postal Code *

E-mail Address

For participants over 18 years old

Mobile Phone

For participants over 18 years old

Emergency Contact *

Who should we contact in case of emergency?

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 *

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.

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.

Demographic Data

Our funders would like to know more about who we serve. Please help us by providing answers to the questions below.

Ethnicity

Is the participant 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 participant’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 me/my child and use those images for publication purposes, whether electronic, print, digital or video.

Please do not photograph me.

Dunes Learning Center Agreement of Participation and Release of Liability *

I certify that the above information is true, accurate and complete. I recognize there is an element of risk in any outdoor activity and I voluntarily assume that risk. I certify that I am fully capable of participating in Dunes Learning Center (DLC) activities and do so as a voluntary participant. In consideration of DLC providing the Activities, I hereby release any claims for personal injury or property damage against DLC (and its agents, employees, directors, officers, and volunteers), arising out of ordinary negligence. I also release such claims arising out of any act by anyone not under control of DLC. I have read, understand, and accept the terms and conditions stated herein and acknowledge that this agreement shall be effective and binding upon me during the entire period of participation in Dunes Learning Center activities. If I am a minor, by indicating my agreement below, my parent or legal guardian makes this certification and provides this release on my behalf.

I agree

Submit

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