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HARMONY SCHOOL OF NATURE
8120 W. CAMP WISDOM RD. DALLAS, TX 75249
Tel: 972-296-1000
Fax: 972-296-2125
PARENT APPROVAL FORM FOR HIGH SCHOOL STEM LEADERSHIP CAMP-2015
Event Name
: HIGH SCHOOL STEM LEADERSHIP CAMP-2015
Location
: UT Dallas, 800 West Campbell Road Richardson, TX 75080
Date of Event:
GIRLS: May 29th - June 2nd, 2015
BOYS: June 3rd – June 7th, 2015
Departure and arrival time: Will be announced later.
Fee: $250.00 (Scholarship is available upon request. Please fill out the scholarship application form)
Due Date: Friday, May 8, 2015 (turn it into Front office with the money)
Dear High School Students and Parents,
Harmony School of Nature proudly announces that this summer you have a great summer camp opportunity at The
University of Texas Dallas (UTD)! The University of Texas at Dallas Welcomes Harmony Students for Residential Camp
Experience.
HIGHLIGHTS
- Morning & afternoon classes.
- Leadership talks
- College information sessions
- Swimming & recreational sports
- Stay in new Residential dorm facility.
Event Coordinator:
Mr. Altun
aaltun@harmonytx.org
The first page may be kept by the parents. Please fill out, sign the 2nd page along with the UT Dallas
medical information and release form and have your child return them to the front office by the due date.
Parent approval may not be obtained over the phone. All students should be promptly picked up after the
event. Parents assume the liability of the children not picked up timely. Call the event coordinator(s) to
make arrangements if needed.
HARMONY SCHOOL OF NATURE
8120 W. CAMP WISDOM RD. DALLAS, TX 75249
Tel: 972-296-1000
Fax: 972-296-2125
PARENT APPROVAL FORM FOR HIGH SCHOOL STEM LEADERSHIP CAMP-2015
Event Name
: HIGH SCHOOL STEM LEADERSHIP CAMP-2015
Location
: UT Dallas, 800 West Campbell Road Richardson, TX 75080
Date of Event:
GIRLS: May 29th - June 2nd, 2015
BOYS: June 3rd – June 7th, 2015
Departure and arrival time: Will be announced later.
Fee: $250.00 (Scholarship is available upon request. Please fill out the scholarship application form)
Due Date: Friday, May 8, 2015 (turn it into Front office with the money)
Student Gender: (Please check one) Female
Male
T-Shirt Size: (Please check one)
S
M
L
XL
2XL
 3XL
 4XL
This is to certify that (student’s full Name) ______________________________ Grade: _____ has my permission to go on the event
mentioned above. In case of emergency, I may be reached at: (Telephone#) ________________________ or the numbers
provided in the Emergency Form.
I, the parent/guardian: By signing, understand that the student must abide by all district policies of the Harmony Science Academy
School District handbook. Any failure to adhere to these policies will result in disciplinary action.
I understand and agree that the trip is a school sponsored activity and function. This release is intended to cover all injuries of every
name, type, kind or nature, and personal property damage, if any, which may be sustained or suffered from any cause connected
with or arising out of, or from participation in the listed events. I understand I am responsible for transportation costs if my child is
required to return home for disciplinary measures. By signing this form parent(s) give(s) consent to his/her child to take the
transportation provided by school or teacher. Means of transportation could be any public, rental or private vehicles driven by an
adult.
Print Name of Parent/Guardian: ______________________________________Date: ________________
Signature: _____________________________
Emergency Medical Release Form
Student’s Name ________________________________________________________________________________________
Printed Parent/Guardian’s name ___________________________________________________________________________
Cell Phone _________________________Work Phone ____________________ext._____ Home Phone _________________
Known Allergies_________________________________________________________________________________________
Medication ____________________________________________________________________________________________
Additional Medical Info We Need ______
__________________________________________________________________
In the event of emergency, I authorize emergency treatment to be administered to my child and I agree to cover all fees involved with the care of
my child.
___________________________________
Parent/Guardian Signature
_______________
Date
EXHIBIT B4-B
THE UNIVERSITY OF TEXAS AT DALLAS
MEDICAL INFORMATION AND RELEASE FORM — MINOR
(To be Completed by Parent or Legal Guardian. Please Print Clearly)
Name ______________________________________________________________________________________________________________
First
Last
Address ___________________________________________________________________________________________________________
City ___________________________________________ State _______ Zip __________0DMRUBBBBBBBBBBBBBBBBBBBBBBB
Telephone Number (
)____________________ Birthdate _______ / _______ / _______ 0DOH)HPDOH
Area Code
Emergency contact persons and phone numbers:
Name __________________________________________________
Name _________________________________________________
Relation ________________________________________________
Relation _______________________________________________
Telephone Number-day (____) _____________________________
Telephone Number-day (____) ____________________________
Telephone Number-night (____) _____________________________
Telephone Number-night (____) ____________________________
Medical Information: Physician Information
Name __________________________________________________
Dentist Information
Name _________________________________________________
Address ________________________________________________
Address _______________________________________________
Telephone Number-office (____) ____________________________
Telephone Number-office (____) ___________________________
Telephone-emergency (____) ________________________________
Telephone -emergency (____) ______________________________
Allergies ___________________________________________________________________________________________________________
'R\RXKDYHKHDOWKLQVXUDQFH"<HV1RHealth Insurance Company _______________________ Telephone (____) _______________
Group # _____________ Policy # _______________
I.D. # _________________________________________________
Medication(s) you are taking (including dosage) ___________________________________________________________________________
Date of last Tetanus/Diphtheria Inoculations_______________________________ Blood type $2%$%$2%$%
Special Health Needs or Concerns _______________________________________________________________________________________
EMERGENCY MEDICAL AUTHORIZATION
I, the undersigned parent or legal guardian of ___________________________________, do hereby authorize The University of Texas at
(name of minor)
Dallas and its designated representatives to consent, on my behalf, to any medical/hospital care or treatment to be rendered to
_________________________________ upon the advice of any licensed physician. I agree to be responsible for all necessary
(name of minor)
charges incurred by any hospitalization or treatment rendered pursuant to this authorization.
The effective dates for this authorization are ____________________ through _____________________.
By signing this authorization, I represent to The University of Texas at Dallas that I have legal authority to provide consent for this
minor child.
_________________________________________________________ Date: ____________________________________________________
(Signature of Parent or Legal Guardian)*
_________________________________________________________
(Printed Name of Parent or Legal Guardian)
Privacy Statement: With few exceptions, you are entitled on your request to be informed about the information U.T. Dallas collects about you. Under
Sections 552.021 and 552.023 of the Texas Government Code, you are entitled to receive and review the information. Under Section 559.004 of the Texas
Government Code, you are entitled to have U.T. Dallas correct information about you that is held by us and that is incorrect.
Original: Custodian
Copy: Faculty or Staff member traveling with the group.
*SIGNATURE REQUIRED ON COMPLETED FORM FOR PARTICIPATION IN THE ABOVE-REFERENCED ACTIVITY AND/OR TRAVEL
Rev. 7/28/2011
EXHIBIT B4
RELEASE AND INDEMNIFICATION AGREEMENT FOR MINOR PARTICIPANTS
PARTICIPANT: (Name and Address)
INSTITUTION:
__________________________________________
The University of Texas at Dallas (UTD)
Name (last name first - please print or type)
__________________________________________
Address
__________________________________________
(School/Administrative Division)
__________________________________________
City, State, Zip Code
__________________________________________
(Program/Administrative Unit)
Check here if you are not a registered UTD student.
IDENTIFYING DESCRIPTION OF ACTIVITY AND/OR TRAVEL: _____________________________________
_________________________________________________________________________________________________
MODE OF TRANSPORTATION: ___________________________________________________________________
PRINCIPAL LOCATION(S): _________________________________________ DATE(S): ____________________
I am the Parent/Guardian of the above-named Participant who is under eighteen years of age and has voluntarily applied to
participate in the above Activity and/or Travel. I am fully competent to sign this Agreement.
I give permission for Participant to participate in the above-referenced Activity and/or Travel. I acknowledge that the nature of
the Activity and/or Travel could possibly expose Participant to hazards or risks that could result in Participant's illness, personal
injury or death and I understand and appreciate the nature of such hazards and risks. I grant UTD and its employees full authority
to take whatever actions they may consider to be warranted under any circumstances regarding the protection of participant’s
health and safety. I understand and agree that if participant does not comply with all the rules, code of conduct, and instructions
relating to this Activity and/or Travel, UTD has the right to terminate his/her participation in this activity without refund.
In consideration of Participant being permitted to participate in the Activity and/or Travel, I hereby accept all risk to Participant's
health and of his/her injury or death that may result from such participation, including transportation and all other adjunct
activities, and I hereby release UTD, its governing board, officers, employees and representatives from any and all liability to
Participant, Participant's personal representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action
for loss of or damage to Participant's property and for any and all illness or injury to Participant's person, including his/her death,
that may result from or occur during Participant's participation in the Activity and/or Travel, whether caused by any type of
negligence of UTD, its governing board, officers, employees, or representatives, or otherwise. I further agree to indemnify and
hold harmless UTD and its governing board, officers, employees, and representatives from liability for the injury or death of any
person(s) and damage to property that may result from Participant's negligent or intentional act or omission while participating in
the described Activity and/or Travel.
I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF ALL CLAIMS AND CAUSES OF ACTION
FOR PARTICIPANT’S INJURY OR DEATH OR DAMAGE TO PARTICIPANT’S PROPERTY THAT OCCURS WHILE PARTICIPATING IN
THE ABOVE DESCRIBED ACTIVITY AND/OR TRAVEL AND THAT IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY
LIABILITY FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY PARTICIPANT’S NEGLIGENT OR
INTENTIONAL ACT OR OMISSION. THIS AGREEMENT SHALL BE CONSTRUED IN ACCORDANCE WITH THE LAWS OF THE STATE OF
TEXAS, WHICH SHALL BE THE FORUM FOR ANY LAWSUITS FILED UNDER OR INCIDENT TO THIS AGREEMENT OR ACTIVITY.
__________________________________________
Signature of Parent/Guardian*
__________________________________________
Printed Name of Parent/Guardian
__________________________________________
__________________________________________
Signature of Witness
__________________________________________
Printed Name of Witness
Date Signed: ____________________________________________
Address (if different from Participant's Address)
Date Signed:
_________________________________
*SIGNATURE REQUIRED ON COMPLETED FORM FOR PARTICIPATION IN THE ABOVE-REFERENCED ACTIVITY AND/OR TRAVEL
March 2005