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Student Information Form 2023

One form per student.

Student Information Form

This form is required to complete your registration for Outdoor Adventures. Your registration is not complete until both this form and payment are received.

"*" indicates required fields

Student Information

Student

Student Preferred Name:*
This is the name we will put on their nametag.
Examples: he/she/they
MM/DD/YYYY

Additional notes about grade.

Any considerations or restrictions that may be helpful for Dodge staff to know to help ensure a positive experience for everyone. Examples: behavioral considerations, neurodiversity (ADHD/Autism spectrum, anxiety, etc.), dietary restrictions, allergies, medications, etc.
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Safety First

Emergency Contact 1*
The first person who should be contacted if there are any questions or issues (this information is NOT transferred from your payment).
Name
Phone
Relationship to student
Emergency Contact 2
Name
Phone
Relationship to student

Legalities

Dodge Nature Center has permission to use my child's image for Dodge's publications, social media, website, marketing, and/or advertising.

By signing this form, I understand and agree that: A) In the event of an emergency, I give permission for Dodge Nature Center (DNC) to administer first aid and/or obtain emergency medical treatment for my child. If necessary, my child will be transported by ambulance to the nearest emergency room; any cost incurred for transportation and/or treatment will be my responsibility. B) I will be charged $5 for every 15 minutes I am late to pick up my child. C) My child will not be permitted to leave with anyone except the people designated on the check-in sheet or shared at drop-off. D) DNC has the right to dismiss a student without a refund for violating DNC's no-tolerance policy. E) I may need to provide a personal aide, at my own expense, if my child requires supervision beyond DNC's child-to-staff ratio.

Your Typed Signature*
Please double-check your entry; this will be the email we use for all program communications (aside from the payment confirmation).

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