Residence Hall Facility

Fully furnished private bedrooms

More details @ utdallas.edu/conference

Enhanced dining experiences

Summer Leadership Camp in UT-Dallas

Recreational Activities

Indoor facilities: Four racquetball courts, two squash courts, four basketball courts, a 25-yard swimming pool

Outdoor facilities: Basketball courts, Soccer fields, Softball and baseball fields, Tennis courts

EXHIBIT B4-B

*SIGNATURE REQUIRED ON COMPLETED FORM FOR PARTICIPATION IN THE ABOVE-REFERENCED ACTIVITY AND/OR TRAVEL Rev. 7/28/2011

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 __________ Major _______________________

Telephone Number ( )____________________ Birthdate _______ / _______ / _______ Male Female 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 Dentist Information Name __________________________________________________ Name _________________________________________________

Address ________________________________________________ Address _______________________________________________

Telephone Number-office (____) ____________________________ Telephone Number-office (____) ___________________________

Telephone-emergency (____) ________________________________ Telephone -emergency (____) ______________________________

Allergies ___________________________________________________________________________________________________________

Do you have health insurance? Yes No Health Insurance Company _______________________ Telephone (____) _______________

Group # _____________ Policy # _______________ I.D. # _________________________________________________

Medication(s) you are taking (including dosage) ___________________________________________________________________________

Date of last Tetanus/Diphtheria Inoculations_______________________________ Blood type A+ O+ B+ AB+ A- O- B- AB-

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.

EXHIBIT B4

*SIGNATURE REQUIRED ON COMPLETED FORM FOR PARTICIPATION IN THE ABOVE-REFERENCED ACTIVITY AND/OR TRAVEL March 2005

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* Signature of Witness __________________________________________ __________________________________________ Printed Name of Parent/Guardian Printed Name of Witness __________________________________________ Date Signed: ____________________________________________ Address (if different from Participant's Address) Date Signed: _________________________________

THE UNIVERSITY OF TEXAS AT DALLAS

The University of Texas at Dallas P.O. BOX 830688 Richardson, Texas (972) 883-2111

Talent Release Form For valuable consideration, I do hereby authorize The University of Texas at Dallas, and those acting pursuant to its authority to:

a. Record my participation and appearance on videotape, audiotape, film, photograph or any other medium.

b. Use my name, likeness, voice and biographical material in connection with these recordings.

c. Exhibit or distribute such recording in whole or in part without restrictions or limitation for any educational or promotional purpose, which The University of Texas at Dallas, and those acting pursuant to its authority, deem appropriate.

d. Exhibit or distribute any written documentation in whole or in part without restrictions or limitation for any educational or promotional purpose, which The University of Texas at Dallas, and those acting pursuant to its authority, deem appropriate.

This release shall remain in effect unless revoked in writing. Name: ___________________________________________________________ Address: ___________________________________________________________ Phone No.: ________________________ Email: ___________________________ Signature: ______________________________________ Date: _______________ Parent/Guardian Name: ______________________________________________ ( if under 18 ) Parent/Guardian Signature: ________________________ Date: _______________ ( if under 18 ) Witness Signature: _______________________________ Date: _______________

2

SUMMER LEADERSHIP CAMP RELEASE AND WAIVER OF LIABILITY AGREEMENT

This agreement is by and between Cosmos Foundation, Inc. d/b/a Harmony Public Schools (“Harmony”), a Texas Open-Enrollment Charter School, and the undersigned Student and Parent or Legal Guardian, and concerns the Student’s participation in the HARMONY SUMMER LEADERSHIP CAMP. For the purposes of this agreement, the HARMONY SUMMER LEADERSHIP CAMP includes any activities involving use of the education facilities located at New Braunfels, including, but not limited to, educational instruction, group or individual study sessions, recreational activities, free play, food or beverage consumption, and sleeping. In addition, the HARMONY SUMMER LEADERSHIP CAMP may include activities conducted off the premises, as well as transportation to and from these activities.

Information

Student Name: ______________________________________________________ Student ID #: _______________________ Male: ☐ Female: ☐

School: _____________________________________________________ Class/Grade Level: ________ Dates of Participation: ________ - ________

Parent(s) or Legal Guardian(s): __________________________________________________________ Email: ______________________________

Address: ________________________________________________________________________________________________________________

Home Tel.: _______________________________ Work Tel.: ________________________________ Cell: __________________________________

Acknowledgement and Consent The undersigned Student and Parent/Legal Guardian hereby gives permission for the Student to participate in the Harmony Study Dorm Program and all related activities for the days indicated above. The undersigned has received and read all the information relating to the Harmony Study Dorm Program and is aware of the guidelines and policies applicable to the Student, including the rules of student conduct, during participation in the program.

The undersigned acknowledges the risks and dangers associated with participation in the Harmony Study Dorm Program, which could result in property damage or bodily injury, including death or permanent injury, and may be caused by the action, inaction, or negligence on the part of Harmony, its Board of Directors, officers, servants, agents, or employees. Further, the undersigned acknowledges and accepts that there may be risks not known or not reasonably foreseeable at this time. THE UNDERSIGNED UNDERSTANDS AND ASSUMES ALL RISKS INHERENT TO THE HARMONY STUDY DORM PROGRAM AND RELATED ACTIVITIES, WHETHER KNOWN OR UNKNOWN, AND THAT BY SIGNING THIS DOCUMENT, IS GIVING UP ITS RIGHT TO SUE.

Release and Waiver of Liability In consideration for permitting the Student to participate in the Harmony Study Dorm Program, the undersigned Student or Parent/Legal Guardian, on behalf of himself/herself, the minor Student, and his/her respective family members, spouses, heirs, assigns, and personal representatives, voluntarily RELEASES, WAIVES, DISCHARGES, and PROMISES NOT TO SUE Harmony Public Schools, its Board of Directors, or any of its officers, servants, agents, or employees (the “Releasees”) from any and all liability, claims, demands, and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, sustained by the Student, or to any property belonging to the Student, whether caused by the negligence of the Releasees, or otherwise, while participating in the Harmony Study Dorm Program, or while in, on or upon the premises where the Harmony Study Dorm Program is being conducted, or in transportation to and from said premises.

All parties agree that this Release and Waiver of Liability shall be construed in accordance with the laws of the State of Texas, and that if any portion of this agreement is held invalid, the other provisions shall continue in full force and effect. This Release and Waiver of Liability shall be a bar to nay recovery by the Student and/or the Parent(s) or Legal Guardian(s) in any action instituted by any of them to recover for loss suffered as a result of participating in the Harmony Study Dorm Program. Signature of Student and Parent/Legal Guardian for Students Who Are Minors: I certify that I am the custodial parent or am the Legal Guardian of the Student. I HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND AND AGREE TO ITS TERMS. I AM AWARE THAT THIS AGREEMENT INCLUDES A RELEASE AND WAIVER OF LIABILITY AND AN ASSUMPTION OF RISK.

Student’s Signature: ____________________________________________________________________ Date: _____________________________ Parent or Legal Guardian’s Signature: ______________________________________________________ Date: _____________________________

3

SUMMER LEADERSHIP CAMP CONSENT TO MEDICAL TREATMENT/RELEASE Student Name: _____________________________________________________ Date of Birth: _______________________ Age: ___________ As the natural parent and/or the legally authorized guardian of the aforementioned minor, I grant my authorization and consent for the respective officers, directors, volunteers and employees of Cosmos Foundation, Inc. d/b/a Harmony Public Schools and the HARMONY SUMMER LEADERSHIP CAMP, to administer general first aid treatment for any minor injuries or illnesses experienced by the Student. If the injury or illness is life threatening or in need of emergency treatment, I authorize the Supervising Adult to summon any and all professional emergency personnel to attend, transport, and treat the participant and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur. It is understood that this authorization is given in advance of any such medical treatment, but is given to provide authority and power on the part of the Supervising Adult in the exercise of his or her best judgment upon the advice of any such medical or emergency personnel. This authorization is effective commencing on the _____day of ____________________, 2015 and expiring on the ______day of ___________________, 2015. I agree to authorize release of any medical information to process insurance claims and request payment of benefits to the physicians or supplier for services described, and to provide any other consent(s) required by federal and state law to effectuate such release. I understand that should the insurance not cover this illness/injury, I will be responsible for payment in full of any charges incurred. MEDICAL HISTORY Does the Student have a known history of: (Circle Y/N)

A. Birth Deformities (one eye, kidney, etc.) YES NO B. Medical conditions currently under treatment YES NO C. Preexisting injuries currently under treatment YES NO D. Fractures or other disability type injuries YES NO E. Allergy (drugs, food, asthma, etc.) YES NO F. Mental disorder or convulsions YES NO G. Known past illness of more than one week YES NO H. Contact lens or glasses YES NO

Explain above questions answered “yes” ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ I hereby state that Cosmos Foundation, Inc. d/b/a Harmony Public Schools and the Harmony Summer Ledaership Program are not responsible, individually or collectively, for any preexisting injury or illness of the above participant. Parent or Legal Guardian Signature (Required) Parent or Legal Guardian Name (Please Print)