National Institute in Forensics

UTNIF
University of Texas
National Institute in Forensics
Name of Student: _______________________________________________________
Date of Birth: _________________
Perm Address: _______________________________________
_______________________________________
City: ______________ State: ____ Zip: ______
Parent/Guardian Names: ______________________________________________________
Summer, 2016
and beyond
Phone Number(s):
Home: _____________ Work: ______________ Mobile: _______________ (Mother, if applicable)
Home: _____________ Work: ______________ Mobile: _______________ (Father, if applicable)
AGREEMENTS
1. I agree to respect the dignity, rights and property of others.
2. I agree to ride only in vehicles approved by the UTNIF. I understand that I am not permitted to drive any vehicle while at the UTNIF.
3. I agree to be present in my assigned room for assigned room checks each night. I agree to remain in the dormitory from 10:30 PM until 6:00 AM each night.
4. I agree that I will not have unauthorized visitors in the dormitory at any time.
5. I agree to arrive on time and participate actively in all scheduled institute activities.
6. I agree to behave in an orderly fashion in university libraries, classrooms, and other facilities.
7. I agree that I will refrain from defacing any library materials
8. I agree to remain free of any drugs (including alcohol) not specifically prescribed to me by a legal physician.
9. I agree that I will not have firearms or any other weapons in my possession while attending the UTNIF.
10. I agree to pay for any fines incurred while at the University of Texas.
11. I agree to not check out books from the library for any other person, including staff members, and understand that all fines accrued will be the debt of my parents and myself.
12. I understand that once admitted to the institute, all tuition and fees are non-refundable, even should the student or parent/legal guardian choose to withdraw the student from the camp
at any time during the session(s).
13. I agree to abide by all rules both written and stated expressed by institute staff, instructors, and administrators.
Student Understanding:
I have studied each of these agreements, and by my signature, I indicate that I understand and pledge compliance with each during the time I am at the institute.
Student Name: ________________________ Date: _________
Signature: ________________________________
Parental Understanding:
I have studied each of these agreements and by my signature I indicate that I understand that breaking the agreements warrants expulsion of the participants and full
forfeiture of all fees paid to the UTNIF. I also understand that I will be responsible for all fines incurred by the above named student and agree to pay them.
Parent or guardian name: _________________________ Date: _________
Signature: _______________________________
OFF-CAMPUS PERMISSION
Often, institute students will want to go off-campus to shop, eat, or for recreation during an off-time. Students without the following parental permission will NOT be allowed these off-campus privileges, and will be restricted to pedestrian travel between the dormitory and assigned classrooms except in the event of transportation for emergency treatment.
I have legal custody of ____________________________ (child's name) and alone may authorize the student to depart the U.T. campus or the designated dormitory for any reason or with any
person regardless of relationship. I hereby authorize the above mentioned student to leave the U.T. campus or the designated dormitory and waive liability from the University of Texas National
Institute in Forensics and/or its agents for incidents occurring while not on the U.T. campus or in the designated.
Signature of Parent/Legal Guardian:__________________________
UTNIF
Dept. of Communication Studies
1 University Station
Mail Code A1105
Austin, Texas 78712-1105
UTNIF Office: 512-471-5518
Fax: 512-232-1481
Date:____________
RELEASE AND INDEMNIFICATION AGREEMENT FOR MINORS ATTENDING SUMMER CAMPS
The University of Texas at Austin
PARTICIPANT:
Name (last name first- please print or type)
Address
City, State, Zip Code
DESCRIPTION OF ACTIVITY OR TRIP: Attendance at the University of Texas National Institute in Forensics
LOCATION(s) of activity or trip:
Austin, Texas
DATE(s) of activity or trip: FROM
20
TO
20
I am the Parent/Guardian of the above-named Participant, who is under eighteen years of age and I am fully competent to sign this
Agreement.
I give permission for Participant to participate in the above-referenced Activity or Trip. I acknowledge that the nature of the Activity or
Trip may expose Participant to hazards or risks that may result in Participant’s illness, personal injury or death and I understand and
appreciate the nature of such hazards and risks.
In consideration of Participant being permitted to participate in the Activity or Trip, I hereby accept all risk to Participant’s health and of
his/her injury or death that may result from such participation and I hereby release The University of Texas at Austin, 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 or Trip, whether caused by negligence of The University of Texas at Austin, its governing board, officers, employees, or
representatives, or otherwise. I further agree to indemnify and hold harmless The University of Texas at Austin 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 negligence or intentional act or omission while participating in the described Activity or Trip.
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 DESCRIBED ACTIVITY OR TRIP AND 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 NEGLIGENCE OR INTENTIONAL ACT OR OMISSION.
Signature of Parent/Guardian
Signature of Witness
Printed Name of Parent/Guardian
Printed Name of Witness
Date signed:
Address (if different from Participant’s address)
Date signed:
20
UTNIF
Dept. of Communication Studies
1 University Station
Mail Code A1105
Austin, Texas 78712-1105
UTNIF Office: 512-471-5518
Fax: 512-232-1481
20
THE UNIVERSITY OF TEXAS AT AUSTIN
Information Technology Services, Networking and Telecom
RELEASE AND INDEMNIFICATION AGREEMENT (v1.0)
Participant: (Name and Address)
_______________________________
_______________________________
_______________________________
Applicable Date(s) ____________________________
I am the Parent/Guardian of the above-named Participant who is under eighteen years of age and am fully competent to
sign this Agreement.
In consideration of Participant being permitted to access the University's network, I hereby acknowledge that:
The Internet allows access to pornographic and other material that may be offensive and not suitable for minors.
The Internet allows access to material that may be copyrighted, and illegal access/download of such material may
be in violation of local, state and/or federal laws.
UT Austin ordinarily does not filter, censor, edit, or regulate the flow of data, software, graphic images, or other materials
on the Internet to or from any of its account holders.
The Internet may from time to time contain hostile programs, viruses, worms, Trojan horses and other files that may
affect or destroy the operation of or information on your computer.
The guidelines for appropriate use of the University network resources may be reviewed at www.utexas.edu/cio/ policies/aup/ I hereby release the above named Institution, its governing board, officers, employees and representatives from any and
all liability related to Participant's potential access to and/or use of inappropriate, illegal, or copyrighted material.
I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF ALL CLAIMS AND
CAUSES OF ACTION FOR PARTICIPANT’S ACTIVITES RELATED TO THE USE OF UNIVERSITY NETWORK RESOURCES, AND IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY LIABILITY CAUSED BY PARTICIPANT’S ACTIVITIES.
Signature of Parent/Guardian
Printed Name of Parent/Guardian
Address (if different from Participant’s address)
Date signed:
20
UTNIF
Dept. of Communication Studies
1 University Station
Mail Code A1105
Austin, Texas 78712-1105
UTNIF Office: 512-471-5518
Fax: 512-232-1481
Please retain these notifications for your records
NOTICE OF PRIVACY PRACTICES
UNIVERSITY OF TEXAS AT AUSTIN
UNIVERSITY HEALTH SERVICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS
TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. HIPAA PRIVACY RULES REQUIRE THAT WE FURNISH YOU WITH THIS NOTICE.
I. Purpose: University Health Services and its professional staff, employees, and volunteers follow the privacy practices described in this Notice. UHS
maintains your medical information in records that will be maintained in a confidential manner, as required by law. However, UHS must use and disclose your medical information to the extent necessary to provide you with quality health care. To do this, UHS must share your medical information as
necessary for treatment, payment, and health care operations.
II. What Are Treatment, Payment, and Health Care Operations Treatment includes sharing information among health care providers involved in your
care. For example, your physician may share information about your condition with the pharmacist to discuss appropriate medication or with radiologist
or other consultants in order to make a diagnosis. UHS may use your medical information as required by your insurer to obtain payment for your treatment. We also may use and disclose your medical information to improve the quality of care, e.g., for review and training purposes.
III. What Are Other Ways UHS May Use Your Medical Information Your medical information may be used, unless you ask for restrictions on a specific
use of disclosure for the following purposes:
• Appointment reminders.
• To inform you of treatment alternatives or benefits or services related to your health. (You will have an opportunity to refuse to receive this
information.)
• To carry out health care treatment, payment, and operations functions through business associates, e.g., to install a new computer system.
• Worker’s Compensation. (Your medical information regarding benefits for work-related illnesses may be released as appropriate.
• Health oversight activities, e.g., audits, inspections, investigations, and licensure.
• Certain research projects.
• To prevent a serious threat to health or safety.
• Law enforcement (e.g., in response to a court order or other legal process; to identify or locate an individual being sought by authorities;
about the victim of a crime under restricted circumstances; about a death that may be the results of criminal conduct; circumstances relating
to reporting information about a crime.)
• Disaster relief agency if injured in a disaster.
• National security and intelligence activities.
• Protection of the President or other authorized persons for foreign heads of state, or to conduct special investigations.
• Lawsuits and disputes. (We will attempt to provide you advance notice of a subpoena before disclosing the information.)
NOTICE OF FREEDOM OF ARTISTIC AND INTELLECTUAL EXPRESSSION POLICY
UNIVERSITY OF TEXAS AT AUSTIN
NATIONAL INSTITUTE IN FORENSICS
The University of Texas Forensics program, including the National Institute in Forensics, is aware that some performance materials, including selections of prose, poetry, drama, news material, research, and original speeches, may be deemed by some as obscene, profane, indecent, or otherwise
unsavory in individual contexts. The program is also aware that in the course of academic speechmaking and debate, controversial subject matter may
become part of the dialogue about issues such as race, gender, sexual identity, and other ideologically relevant issues. It is the philosophy of the program that open and unfettered expression of artistic and intellectual endeavors is fundamental to communication education and to the development of
students as performers, debaters, presenters, and entertainers. In accordance with the University of Texas System Handbook of Operating Procedures, the UTNIF practices a strict code of non-censorship with regard to material selected and/or expressed by its students and staff in the process of
their intellectual and artistic endeavors:
The University also is committed to the principles of free inquiry and expression. Members of the University community have the right to
hold, vigorously defend, and express their ideas and opinions, to flourish or wither according to their merits. Respect for this right requires that members of the community tolerate expression of views that they find abhorrent. But whatever the legal boundaries of free
speech, the members of an educational community should adopt voluntarily standards of civility that reflect mutual respect, understanding, and sensitivity among its diverse racial, ethnic, and cultural groups.
The UTNIF endorses the vigorous expression of even controversial views and subject matter as those views relate to performative and argumentative
endeavors and encourages the open exchange of ideas, even when those ideas come into conflict with each other, with an eye toward understanding,
analysis, and decision-making.
By the same token, all students involved in the UTNIF reserve the right to choose not to perform or express material that violates their individual opinions, racial or ethnic beliefs, religious principles, or morals. Requests to refrain from performance should be made directly to the appropriate staff member and will be enforced by the Director of UTNIF.
The University of Texas at Austin
Youth Protection Program Consent for
Treatment/Immunizations of a Minor
FOR UNIVERSITY HEALTH SERVICES USE ONLY
Patient Name: __________________________________
Medical Record #: _______________________________
DOB: _______________
Gender: _______________
Provider: ____________
Date: _________________
This form must be completed and returned to the camp director prior to the program start date.
Personal Information
Camper’s Last Name _____________________________________ First Name________________________ Birthdate___________
M
F
Specify program your child will attend____________________________________________________________________________
State______
Zip____________
Address______________________________________________ City______________________
Home Phone__________________________________________ E-mail Address__________________________________________________
Parent/Guardian 1_____________________________________ Daytime Phone_______________ Place of employment____________________
Parent/Guardian 2_____________________________________ Daytime Phone_______________ Place of employment____________________
Health Insurance Carrier_________________________________ Policy Number________________ Plan Number___________________________
Is physician authorization needed?
Yes
No
Family Physician_______________________
Phone____________
In case of emergency, please notify
If neither parent nor guardian is available in an emergency, please contact:
1. ___________________________________________________________ Phone________________________
2. ___________________________________________________________ Phone________________________
Health History
Allergies: _______________________________________________________________________________________________________________
Date of most recent tetanus immunization:__________________________________________
Please list any major past illnesses (contagious and non-contagious): ________________________________________________________________
Please list any major operations or serious injuries (include dates): ________________________________________________________________
Has the youth ever been hospitalized? No
Yes
Does the youth have any chronic or recurring illness?
No
Yes
Is there anything else in youth’s health history that the camp staff should know? _____________________________________________________
Are there any activities from which the youth should be restricted?
No Yes
Does the youth have any special dietary restrictions? No
Yes If YES, explain: __________________________________________________
Does the youth wear any medical appliances (glasses, contact lenses, orthodonture, etc.)?
No Yes If YES, explain: _______________________
Is the youth’s immunization record current showing that the youth has been immunized in accordance with the Texas Department of State
Health Services Minimum State Vaccine Requirements? No Yes If No, attach official documentation of TDHS exemption from
immunizations for Reasons of Conscience or a Physician’s Statement of medical contraindications.
This authorizes The University of Texas at Austin physicians, medical personnel and camp sponsors to release information concerning the medical
status, medical condition, injuries, prognosis, diagnosis and related personally identifiable health information of
_________________________________ (participant name) to camp staff. This information includes injuries or illnesses relevant to participation in
the above named camp at The University of Texas at Austin.
SIGNATURE OF CAMPER
DATE
SIGNATURE OF PARENT/LEGAL GUARDIAN
DATE
CAMPER’S DATE OF BIRTH
PROGRAM NAME
Will the youth need to take any medication at camp?
No
Yes
If YES, please list the specific prescription or over-the-counter medications below, reasons for medication, and daily dosage.
Medication
Reason(s) for Medication
Daily Dosage/Time(s) Taken
-
-
-
-
The University of Texas at Austin sponsored _____________________________ (camp/program name) designated personnel will not dispense nonprescription or prescription medication to the above named participant until the following information has been completed by a parent or guardian.
It is the responsibility of the parent/guardian to give the medication directly to the camp director or designated staff member in individual dosage
containers, original prescriptions containers, or envelopes clearly labeled with dosage instructions on the first day of camp.
I ______________________________________, the parent/guardian of _______________________________________ give permission to the staff
of the _________________________________ (camp/program name) to administer the prescription medications listed above.
My child may possess and self-administer the following medicine: __________________________________________________________________
and I affirm that my child understands and agrees that he/she will use the medication only according to dosage instructions, and will not share or
otherwise provide medication to any other person while at camp, and failure to do so is a violation of camp rules that will result in disciplinary
action, up to and including removal from camp.
I hereby release The University of Texas at Austin, its Board of Regents, officers, employees, and representatives from any and all liability in any
way resulting or arising from the administering of the above medication.
SIGNATURE OF PARENT/LEGAL GUARDIAN
DATE
I, the undersigned, as the parent or legal guardian of _____________________________ (a minor) hereby authorize such diagnostic, medical
and/or surgical treatment of such minor as may be considered necessary or appropriate under the circumstances for the treatment of any illness
or injury of the minor. The attending provider, appropriate staff, and The University of Texas at Austin and is officers, regents, and employees shall
not be responsible in any way for any consequences from said diagnostic, medical, and/or surgical treatment and are hereby released from any
and all claims and causes of action that may arise, grow out of, or be incident to such diagnosis, treatment, or surgery insofar as the law allows and
provided that these services are performed with ordinary care and to the best of their ability.
SIGNATURE OF PARENT/LEGAL GUARDIAN
DATE
PRINT NAME
I have received a copy of University Health Services Notice of Privacy Practices as required by HIPAA Privacy Rules.
The University of Texas at Austin honors the privacy of the participants in its programs and complies with the national regulations regarding
health information. Follow this link http://www.healthyhorns.utexas.edu/privacy.html to the University Health Services Notice of Privacy
Practices.
SIGNATURE OF PARENT/LEGAL GUARDIAN
DATE
Please Return to Camp Director:
Name of Program: ____________________________________________________________________________
Camp Director: _____________________________________
Camp Director Phone: ______________________
Camp Director Fax: _____________________
Camp Director Mailing Address: _________________________________________________________________
Revision Date:
12/7/2015
The University of Texas at Austin
Youth Protection Program
Media Release
Camper’s Name: ______________________________
Program Name/Session: ________________________
This form must be completed and returned to the camp director prior to the program start date.
I hereby grant full permission to The University of Texas at Austin to prepare, record, use, reproduce,
publish, distribute and exhibit my child’s name, picture, portrait, likeness or voice, or any or all of them
in or in connection with any medium, including, but not limited to, the production of web sites, still
photography, motion picture film, television tape, film or sound track recording, scientific publication,
or any other purpose The University of Texas at Austin deems appropriate.
I hereby waive all rights of privacy or compensation, which I may have in connection with the use of my
child’s name, picture, portrait, likeness or voice, or any or all of them, in or in connection with said
media, including, but not limited to, web sites, still photography, motion picture film, television tape,
film or sound track recording and any use to which the same or any material therein may be put,
applied or adapted by The University of Texas at Austin.
This consent and waiver will not be made the basis of a future claim of any kind against The University of
Texas at Austin and any of its agencies.
SIGNATURE OF PARENT/LEGAL GUARDIAN
DATE
PRINT NAME
PLEASE RETURN TO CAMP DIRECTOR:
Name of Program: _________________________________________________________
Camp Director: ____________________________________________________________
Camp Director Phone: ____________________
Camp Director Fax: __________________
Camp Director Mailing Address: ______________________________________________
Revised 10/15/2015