Please list any allergies, medical conditions, diagnosed behavioral or learning disabilities that we should know about.

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 for my student’s participation. I certify that my student is fully capable (except where noted) of participating in Dunes Learning Center (DLC) activities and does 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 DLC activities. As the legal guardian, 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 student. In the event I cannot be reached in an emergency; I hereby give permission to the physician selected by the group, school or DLC staff to secure and administer treatment; including hospitalization, injection, anesthesia, surgery, and transfusion for my student 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, communicable diseases, or for any bodily injuries, or the results thereof, incurred and suffered by the participant 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 the participant or others. I hereby grant Dunes Learning Center the right to photograph my child and use those images for publication purposes, whether electronic, print, digital or electronic. 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.

Select all that apply.