University of Texas UTNIF National Institute in Forensics Name of Student: _______________________________________________________ Date of Birth: _________________ Perm Address: _______________________________________ _______________________________________ City: ______________ State: ____ Zip: ______ Parent/Guardian Names: ______________________________________________________ Summer, 2009 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 privi- leges, 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:__________________________ Date:____________ UTNIF Dept. of Communication Studies 1 University Station Mail Code A1105 Austin, Texas 78712-1105 UTNIF Office: 512-471-1957 Fax: 512-232-1481 STUDENT NAME: _____________________________ TREATMENT CONSENT & INSURANCE INFORMATION 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 physician, appropriate staff, and The University of Texas at Austin and its 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. I understand that I will be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization. I have also received a copy of University Health Services Notice of Privacy Practices. Insurance Company: _______________________________ Name of Insured: _____________________ Policy #: _____________ Social Security or ID #: _______________________ Medical Conditions: ____________________________ Allergies: _______________________________ Current Medications: ____________________________ Other: _______________________________ Signature of Parent/Legal Guardian:__________________________ Date:____________ PHYSICIAN AUTHORIZATION PRE-ACTIVITY CLEARANCE EXAMINATION: I hereby certify that I have examined and have found him/her fit to attend and participate in the UTNIF. I know of no impairments, which would limit his/her participation in all camp activities except those that I have listed below. I further certify that he/she is free from any and all contagious diseases. Date of Physical Examination:__________________ (Physical examination must have been completed within the last 12 months) Date of Last Tetanus Booster:___________________ Restrictions and/or Comments: Physician Address:____________________________________________ City:__________ State:________ Zip:__________ Phone:_________________________ Physician’s Signature:______________________________________ Please use this space to tell us any additional information that may be important in addressing the educational needs of the student: RELEASE AND INDEMNIFICATION AGREEMENT FOR MINORS 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 PAR- TICIPATING 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 NEGLI- GENCE OR INTENTIONAL ACT OR OMISSION. Signature of Parent/Guardian Signature of Witness Printed Name of Parent/Guardian Printed Name of Witness Date signed: 20 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: 512-471-1957 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 dis- close 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 treat- ment. 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 selec- tions 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 pro- gram 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 Proce- dures, 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 re- quires 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, understand- ing, 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 opin- ions, racial or ethnic beliefs, religious principles, or morals. Requests to refrain from performance should be made directly to the appropriate staff mem- ber and will be enforced by the Director of UTNIF.