Dear Parents,

UTeach Outreach would like to invite your 6th grader to participate in the UTeach Outreach Science After School Club. Here are some interesting facts about our program:

. Your 6th grader will be participating in an after school science club led by UT students and an AISD teacher at your campus! Club meetings will be once a week for 1.5 hours immediately after school.

. The Science Club will give your child more experience in different fields of science, including physics, chemistry, biology and earth science.

. Some of the science activities that your 6th grader will be able to participate in will be designing experiments to test different areas of science.

. At the end of the semester, your child will participate in the Mini Science Competition. This is a competition with other 6th graders based on the content that will be taught during the semester. Your child will come to UT with other classmates for a day of fun and competition!

. If your 6th grader is interested in participating, contact your student’s science teacher to turn in registration forms. Estimados Padres,

El programa UTeach Outreach quiere invitar a su estudiante del grado 6 a participar en un Club de Ciencia. Aquí están unos datos interesantes de nuestro programa.

 ¡Su estudiante del grado 6 participara en un club de ciencia dirigido por estudiantes de UT y un maestro de la escuela de su niño(a)! Reuniones del club serán una vez por semana de 1.5 horas inmediatamente después de escuela.

 El Club de Ciencia le dará a su niño(a) más experiencias con ciencia incluyendo física, química, biología, y ciencias de la tierra.

 Unas de las actividades de ciencia en que su estudiante del grado 6 podrá participar es desenando experimentos para pruebas de diferentes áreas de ciencia.

 Al fin del semestre, su niño(a) participara en una Mini Competencia de Ciencia. Es una competencia con otras escuelas secundarias sobre las lecciones que se enseñaron durante el semestre. Su niño(a) vendrá a UT con otros compañeros del salón para un día de diversión y competencia.

 Si su estudiante del grado 6 está interesado en participar comuníquese con el maestro de ciencia de su estudiante para entregar formas de inscripción. What is UTeach Outreach?

. UTeach Outreach in Elementary Classrooms has been a partnership between the College of Natural Sciences at the University of Texas at Austin and the Austin Independent School District (AISD) since 1995.

. Each fall and spring semester, UTeach Outreach provides undergraduate students to serve as volunteer instructors who provide science lessons within AISD.

. We reach 6,000 elementary students in schools throughout AISD each year with hands-on science.

¿Que es UTeach Outreach?

 UTeach Outreach en Salones Elementarios ha sido una colaboración entre el Colegio de Ciencias Naturales en la Universidad de Texas en Austin y el Distrito Escolar de Austin (AISD) desde el 1995.

 Cada semestre del otoño y primavera, UTeach Outreach provee estudiantes de la universidad que sirvan como instructores voluntarios que proveen lecciones de ciencia dentro el distrito escolar (AISD).

 Cada año proveemos actividades de ciencia a 6000 estudiantes de primaria en escuelas sobre el distrito escolar (AISD). Dear Parent and Student,

Congratulations! Your 6th Grader has been invited to participate in The University of Texas – Austin sponsored Science After School Club. The club includes hands-on science lessons taught by University of Texas students and a 6th grade science teacher here at ______School. We will meet every ______from ______- ______p.m. and will have a Mini Science Competition over the topics covered with other schools at the end of the year. The Fall 2015 Mini Science Competition will be held on Monday, December 7 th , 2015 from 9:30am – 1 pm. This is a fun competition designed to test student knowledge and skills in areas of science. Parents and family are encouraged to attend and can ride the bus if space is available or provide transportation and parking on your own. The Club meets ______in room ______from ______- ______p.m. First Club meeting: ______Mini Science Competition is Monday, December 7 th , 2015 from 9:30 am – 1 pm at The University of Texas – Austin Competition and Awards – Welch (WEL on UT map) Contact Information: 6th grade Science Teacher

Please return to your Science Teacher by Friday, October 9th, 2015 Permission Slip –Fall 2015 Science Club/Mini Science Competition ____ I give my student permission to participate in the Science Club and attend the Mini Science Competition on Monday, December 7 th , 2015 .

____ I do not give my student permission to participate or attend

____ I may be interested in attending the Mini Science Competition and need more information

After the club meeting my student may be dismissed to: ______another after school program ______parent pick up ______after school bus

Picture and Video Release: As part of the Science Club, I understand that my child will be participating in teaching experiences that will be videotaped and/or photographed. I give permission to have any pictures or videos of my child used for instructional and/or promotional purposes of the UTeach Program, without further authorization. These uses may include, but are not limited to print, video, and electronic media.

Signature: ______Date: ______

Student Name: ______

Parent Name: ______Parent Phone Number: ______

Emergency Contact Name and Number: ______Estimados Padres y Estudiantes,

¡Felicidades! Estudiantes del grado 6 están invitados a participar en un Club de Ciencia de Después de Escuela patrocinado por La Universidad de Texas – Austin. El club incluye lecciones manuales de ciencia divertidas y exitosas impartidas por estudiantes de la Universidad de Texas y un maestro(a) de ciencia del grado 6 de la Escuela ______. Las reuniones del club serán cada ______de ______- ______p.m. y al fin del año tendremos una competencia del Mini Competición de Ciencia con otras escuelas sobre los temas cubiertos. La Mini Competición de Ciencia del Primavera del 2015 se llevara a cabo el lunes, 7 de diciembre de 9:30 a.m. – 1:00 p.m. Esta es una competencia divertida diseñada para evaluar el aprendizaje y habilidades de estudiantes en las áreas de ciencia. Animamos que atiendan padres y familias y pueden venir en el autobús si hay espacio o proveer su propia transportación y estacionamiento.

El Club se reúne los ______en el salón ______de las _____ - ______p.m. Primera reunión del Club: ______La Mini Competición de Ciencia es el lunes, 7 de diciembre La Universidad de Texas – Austin Competencia y Reconocimientos – Welch Building Contacto para Información: Maestro (a) de Ciencia del grado 6

Favor de Regresar esta forma a su maestro(a) de ciencia para el viernes, 9 de octubre del 2015 Forma de Permiso – Club de Mini Competición de Ciencia

___ Yo doy a mi estudiante permiso para participar en el Club de Ciencia y atienda la Mini Competición de Ciencia el lunes, 7 de diciembre.

___ Yo no doy a mi estudiante permiso para que participe o atienda.

___ Me interesaría atender la Mini Competición de Ciencia y necesito más información.

Después de las reuniones del club mi estudiante debe ser despedido al: ______otro programa de después de escuela ______donde padres lo recojan ______autobús de después de escuela

Permiso para Video y Fotografía: Como parte del Club de Mini Competición de Ciencia, entiendo que mi niño(a) participara en experiencias de enseñanza que serán gravadas en videos y/o en fotografías. Doy permiso para que fotografías o videos de mi niño(a) se usen para propósitos de instrucción y promoción del programa UTeach, sin más autorización. Estos usos pueden incluir, pero no limitado a fotos, videos, y media electrónica.

Nombre de Estudiante: ______

Nombre de Padres: ______

Número de Teléfono de Padres: ______

Nombre y Número de Contacto para Emergencia: ______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: UTeach Outreach Field Trip to UT Mode of Transportation: None (provided by AISD) Location of activity or trip: UT Austin Campus Date of Activity: Fall 2015 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: , 2015 Address (if different from Participant’s address) Date signed: , 2015

CONSENT FOR TREATMENT/IMMUNIZATIONS OF A MINOR University-Sponsored Program Participant Information and Consent

Name of Program Participant:______UTEID (if one has been assigned): ______NONE___ Date of Birth:______Address (Street, City, State, Zip Code): ______

______Parent/Guardian Phone Number: HOME ______WORK ______CELL ______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/GUARDIAN ______DATE ______PRINT NAME ______I have received a copy of University Health Services Notice of Privacy Practices as required by HIPAA Privacy Rules.

SIGNATURE OF PARENT/LEGAL GUARDIAN DATE ______PRINT NAME______

Medical Information Related to Minor: Allergies:______Current Medications: ______Date of Last Tetanus Booster: ______Pertinent Medical History: ______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? You 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.) As required by law. IV. Your Authorization Is Required for Other Disclosures. Except as described above, we will not use or disclose your medical information unless you authorize (permit) UHS in writing to disclose your information. You may revoke your permission, which will be effective only after the date of your written revocation. V. You Have Rights Regarding Your Medical Information. You have the following rights regarding your medical information, provided that you make a written request to invoke the right on the form provided by UHS.  Right to request restrictions. You may request limitations on your medical information we use or disclose for health care treatment, payment, or operations (e.g., you may ask us not to disclose that you have had a particular surgery), but we are not required to agree to your request. If we agree, we will comply with your request unless the information is needed to provide you with emergency services.  Right to confidential communications. You may request communication in a certain way or at a certain location, but you must specify how or where you wish be contacted.  Right to inspect and request a copy. You have the right to inspect and request a copy your medical information regarding decisions about your care. We charge a fee for copying, mailing, and supplies. Under limited circumstances, your request may be denied; you may request review of the denial by another licensed health care professional chosen by UHS. UHS will comply with the outcome of the review.  Right to request amendment. If you believe that the medical information we have about you is incorrect or incomplete, you may request an amendment on the form provided by UHS, which requires certain specific information. UHS is not required to accept the amendment.  Right to accounting disclosures. You may request list of the disclosures of your medical information that have been made to persons or entities other than for health care treatment payment or operations in the past years, but not prior to April 14, 2003. After the first request, there will be a charge.  Right to copy of this Notice. You may request a paper copy of this Notice at any time, even if you have been provided with an electronic copy. You may obtain an electronic copy of this Notice at our web site, http://www.utexas.edu/student/health/. VI. Requirements Regarding This Notice. UHS is required by law to provide you with this Notice. We will be governed by this Notice for as long as it is in effect. UHS may change this Notice and these changes will be effective for medical information we have about you as well as any information we receive in the future. Each time you register at UHS for health care services, you may receive a copy of the Notice in effect at the time. VII. Complaints. If you believe your privacy rights have been violated, you may file a complaint with UHS or with the Secretary of the United States Department of Health and Human Services. You will not be penalized or retaliated against in any way for making a complaint to UHS or the Department of Health and Human Services. Contact: Call the UHS HIM Administrator at (512) 475-8432 if:  You have a complaint.  You have any questions about this Notice.  You wish to request restrictions on uses and disclosures for health care treatment, payment, or operations.  You wish to obtain a form to exercise your individual rights described in paragraph V.