Child’s Name Date of Birth Child’s Home Telephone

Child’s Home Address Grade Level He/She is Entering for the 2015-16 School Year:

Parent or Guardian Name(s) Address (if different from child’s address)

Parent/Guardian Contact Informa on Home/Work: Email:

Parent/Guardian Cell Phone Number:

Session Date(s): Please circle one or two weeks only. . 1) June 6-10 2) June 13-17 3) June 20-24 4) June 27 - July 1

Session Level: Please circle only one per application Grades 3-4, 10:00 AM-12:00 PM Grades 5-8, 8:30 AM-12:30 PM

Emergency Contact (name, address, phone number of person to call if parents/guardians cannot be reached) Rela onship

I hereby authorize the childcare opera on to allow my child to leave the childcare opera on ONLY with the following person(s). Please list name & telephone numbers for each. Children will only be released to a person designated by the parent/guardian a er verifica on of ID.

CHECK ALL THAT APPLY: I hereby ___ give ___ do not give – consent for my child to be transported and supervised by the opera on’s employees. 1. TRANSPORTATION: ___for emergency care ___ field trips ___ ride a bus ___ to and from home ___ to and from school

2. FIELD TRIPS: I hereby ___ give ___ do not give – my consent for my child t cipate in field trips. Parent Comments:

3. WATER ACTIVITIES: I hereby ___ give ___ do not give – my consent for my child t cipate in water ac vi es. *Grades 5-8 only ___ wading in the bay* ___ snorkeling* ___ kayaking* ___ ac vi es in the Gulf waters

4. PERMISSION TO BE PHOTOGRAPHED DURING CAMP ACTIVITIES: ___ I DO give permission for my child to be photographed. ___ I DO NOT give permission for my child to be photographed.

5. MY CHILD HAS PERMISSION TO: ___ be released to the care of his/her siblings under 18 years old. Name of sibling(s): ________________________________________________________________ walk to and from UTMSI

6. IMMUNIZATIONS: ___ His/Her immuniza on record is on file at the school and all required immuniza ons and/or tuberculosis tests are current. Vision/Hearing screening records

are also on file.

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION: In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to: Name of Physician: Address: Phone Number:

Name of Emergency Medical Care Facility: Address: Phone Number:

I give consent for the facility to secure any and all necessary emergency medical care for my child. Signature – Parent or Legal Guardian: _____________________________________________________________________________________________________

List any concerns that your child may have, such as allergies, existing illnesses, recent hospitalization or special needs. Program MUST be informed of care requirements two weeks prior to the program start date. ____________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

Name and Address of School Your Child A ends: _____________________________________________________________ School Phone Number: _____________

_________________________________________________________________________________________

Signature – Parent or Guardian

________________________________________ Date

Amount _________________ Paid in Full Y N

Summer Science Program Registration & Release The University of Texas Marine Science Institute &

Mission–Aransas National Estuarine Research

Reserve

Ver. 3/25/16

The University of Texas at Austin, Marine Science Institute MINOR PHOTO RELEASE

Please print

Minor’s Last Name First Middle

Home Address: Street City State Zip Code

Minor’s Date of Birth

Photo Release In consideration of the engagement as a model of the minor named below, and for other good and valuable consideration that I acknowledge as having received, I hereby grant the following rights and permissions to The University of Texas at Austin ("University"), his/her legal representatives and assigns, those for whom Photographer is acting, and those acting with his/her authority and permission. They have the absolute right and permission to take, use, reuse, publish, and republish photographic portraits or pictures of the minor or in which the minor may be included, in whole or in part, or composite or distorted in character or form, without restriction as to changes or alterations from time to time, in conjunction with the minor's own or a fictitious name, or reproductions of such photographs in color or otherwise, and in any and all media now or hereafter known, including the internet, for educational, public relations, publicity and promotional purposes. I also consent to the use of any published matter in conjunction with such photographs. I specifically consent to the digital compositing or distortion of the portraits or pictures, including without restriction any changes or alterations as to color, size, shape, perspective, context, foreground or background. I waive any right that I or the minor may have to inspect or approve any finished product or products or the advertising copy or printed matter that may be used in connection with such photographs or the use to which it may be applied. I hereby warrant that I am a legal competent adult and a parent or legally appointed guardian of the minor, and that I have every right to contract for the minor in the above regard. I state further that I have read the above authorization, release, and agreement, prior to its execution, and that I am fully familiar with the contents of it. This release shall be binding upon the minor and me, and our respective heirs, legal representatives, and assigns.

Signature of Father, Mother or Legal Guardian Date

Witness Signature Date