2015 Exxonmobil Bernard Harris Summer Science Camp

2015 EXXONMOBIL BERNARD HARRIS SUMMER SCIENCE CAMP

ENROLLMENT PACKET

[INSERT THE NAME OF THE UNIVERSITY]

[INSERT CAMP DATES]

This packet contains the enrollment forms for the ExxonMobil Bernard Harris Summer Science Camp at [INSERT UNIVERSITY]. Everyone must complete the following 2015 forms.

Form 001: Enrollment Form

Form 002: Parent/Legal Guardian Approval for Participation

Form 003: Standard Code of Conduct

Form 004: Media Release Form

Form 005: Field Trip/ Excursion Approval

Form 006: Authorization to Release Student Contact Information Form

If you do not want your child’s contact information to be released, you do not have to sign Form 006. If you are requesting to check your child out for a scheduled appointment or event, please complete Form 007. Please note that the Executive Camp Director must approve the request.

Form 007: Request for Short Leave

Form 008: THF Cell Phone Policy

Our camp program requires the use of a cell phone. If your child will be bringing his/her cell phone to camp, please complete Form 008.

The final camp enrollment form to be completed for your child is the Medical Form. It is sent as a separate document so that you can take it to your child’s doctor.

Please check each page before returning to make sure that you have provided all of the information requested and have signed each form. Return completed Enrollment Packet and the completed Medical Form no later than [INSERT DATE] to [INSERT RETURN INFORMATION.

If you have questions or need additional information, please contact [INSERT NAME AND CONTACT INFORMATION].

2015 EXXONMOBIL BERNARD HARRIS SUMMER SCIENCE CAMP

REFERENCE PAGE

Thank you for taking the time to complete the attached forms. Your assistance ensures that all students will have a safe, enjoyable educational experience at this summer’s EMBHSSC at [insert university name here].

Please keep this page for your reference. The remaining pages should be returned to [insert name, address, and due date]. Feel free to make a copy of these pages for your records.

The Harris Foundation (THF) conducts an annual Parent Survey at the end of the camp. The email address you provide on Form 001: Enrollment Form will be used to send you the Parent Survey. Your input is an integral part in continuing to enhance the camp experience for youth and maintain its success.

Further, if you provide an email address for your child, THF will use it when conducting its longitudinal survey of past participants. THF uses this survey to measure the long-term impact of the camp experience on participants’ high school and college course selection, their involvement in STEM extracurricular activities, and their selection of a college major/career. This survey will be administered at the end of each participant’s eighth and twelfth grade year, as well as upon completion of college.

Please note, participation in these surveys is optional. Hard copies will be sent to parents/legal guardians and students should an email address not be available.

2015 EXXONMOBIL BERNARD HARRIS SUMMER SCIENCE CAMP
FORM 001: ENROLLMENT FORM

Please print in black or blue ink or type

Camper’s Name:______Grade Level

Date of Birth:Gender

E-mail Address:

Address:

CityStateZip Code

Home Phone Number:

Parent/Legal Guardian Name

Daytime Phone Number:Cell:

E-mail Address:

Parent/Legal Guardian Name:

Daytime Phone Number:Cell:

E-mail Address:

Alternate Emergency Contact:

Name

Relationship: relative neighborfriend

Daytime Phone Evening Phone:

Cell:

Parent’s SignatureDate

Office Use Only

Dorm/Room NumberDorm (Night) Counselor

2015 EXXONMOBIL BERNARD HARRIS SUMMER SCIENCE CAMP
FORM 001: ENROLLMENT FORM (continued)

Camper’s Name

General Camper Information

In order to make your child’s experience at camp the best possible; we would like some information from you. The camp staff will use the information on this page to enhance your child’s camp experience.

Has your child ever been away from home without a parent?YesNo

If yes, how did he/she cope?

Does your child have any particular fears? (I.e., the dark, water, animals, etc.)

Does your child have any disabilities or special challenges? (i.e. physical, emotional, learning, developmental, social or behavioral)

Does your child have any hobbies or special interests?

Is there anything else we should know about your child to make his/her stay more enjoyable?

2015 EXXONMOBIL BERNARD HARRIS SUMMER SCIENCE CAMP
FORM 002: PARENT/GUARDIAN APPROVAL FOR PARTICIPATION

I/We hereby certify and agree that (“My Child”) Please Print: Child’s Name (First, Middle, Last)

has my/our approval to participate in the Bernard Harris Summer Science Camp to be held [INSERT CAMP DATES], at the [INSERT UNIVERSITY]. I/We understand that this is a two-week camp and signing this form indicates that My Child will attend both weeks.

I/We know the nature of the Camp and My Child’s experience and capabilities and consider My Child to be qualified to participate in the Camp. But I/We acknowledge that there are certain risks of physical injury or illness associated with the Camp’s activities.

In return for My Child’s participation in the Camp: I/we fully and forever RELEASE, WAIVE, DISCHARGE, ACQUIT, INDEMNIFY, HOLD HARMLESS and COVENANT NOT TO SUE, the Harris Foundation (“Foundation”), [INSERT UNIVERSITY] collectively, the “Releases”) (including, but not limited to, each of the Releases’ regents, boards, agents, employees, officers or representatives), from all demands, claims, actions, suits, damages, losses, liabilities, costs and expenses including, but not limited to, court costs and attorneys’ fees from any cause whatsoever-including, but not limited to, travel delays, property damages and loss, bodily injuries, sickness, disease or death-directly or indirectly arising in connection with My Child’s participation in the Camp, irrespective of whether foreseeable or contributed to by any negligent act or omission of any of the Releases or any other party.

I/We recognize that neither the Releases assumes responsibility for or liability for – including costs and attorney’s fees-any accident or injury or damage resulting from any aspect of participation in the Camp. Neither of the Releases is liable for any special, incidental or consequential damages arising out of or in connection with any aspect of participation in the Camp.

Neither of the Releases (including, but not limited to, each of the Releases’ regents, boards, agents, employees, officers or representatives) is responsible for any medical bill incurred as a result of any personal illness or injury to My Child. That medical bill is my/our responsibility.

I/We understand that by signing this document, I/we give up substantial rights that I/we or My Child would have otherwise to receiver damages for any loss occasioned by Releases’ fault, and I/we sign it voluntarily and without inducement.

(Both parents, if possible)

Signature of Parent/Legal GuardianSignature of Parent/Legal Guardian

Daytime Phone (Parent/Legal Guardian)Daytime Phone (Parent/Legal Guardian)

DateDate

2015 EXXONMOBIL BERNARD HARRIS SUMMER SCIENCE CAMP
FORM 003: STANDARD CODE OF CONDUCT

The following is a list of rules and prohibited conduct intended to assist in providing for the health, safety and social well being of everyone attending an EMBHSSC. Any reasonable suspicion that a camper has engaged in such prohibited conduct, or attempted conduct, or violation of any rule will result in the immediate dismissal from the EMBHSSC.

Campers are expected to obey dorm rules and instructions given by Camp Directors, Camp Counselors, and/or Camp Staff.
Campers are expected to adhere to the dress code at all times.
Campers are expected to actively participate in all camp classes and activities.
Campers are not to walk around campus except in groups and accompanied by the Lead Camp Counselor, a Senior Camp Counselor, a Dorm Counselor or other adult camp staff member.
Campers are to check-in with his/her assigned camp counselor(s) at the times specified.
Campers must make sure that the Lead Camp Counselor and/or a Senior Camp Counselor on duty know where he or she is at all times.
Campers are required to be in their assigned class at all times. Bathroom breaks are to occur only between classes and during scheduled breaks.
Disruptive behavior in classes or on field trips/excursions and unexcused absences from any scheduled activity will not be permitted.
Dangerous or threatening conduct, disrespectful behavior, bullying (persistent, offensive, abusive, intimidating, or insulting behavior, which makes the recipient feel upset, threatened, humiliated, or vulnerable) and hazing (conduct that causes or intends to cause psychological, emotional, or physical harm to any person) will not be permitted.
Possessing, using, storing, or transporting firearms, other weapons, explosives, smoke bombs, fireworks, ammunition, or dangerous chemicals are prohibited.
Relatives and friends are not permitted to pick up campers during the week unless approved by the Executive Camp Director. Visitation by parents during the week is discouraged. Visitation from friends is not permitted.
Campers are not permitted to bring electronic devices, pagers, television sets and/or hand-held gaming devices to camp.
Campers are permitted to bring a cell phone to camp if required for the camp’s program and a copy of The Harris Foundation Cell Phone Policy signed by a parent/guardian is on file.
All campers are to be in their room by 9:30 p.m. Lights out at 10:30 p.m. No visitors allowed.

As a participant in the EMBHSSC, I agree to participate in the entire program and conduct myself in a way to bring credit to my family, my school, my community, the BHSSC, and myself.

Camper’s SignatureDate

I/We have read and will adhere to the above Standard Code of Conduct for the EMBHSSC. We understand that violation of any of the above rules and/or prohibited conduct will be cause for immediate dismissal from the camp.

Camper’s SignatureDate

Signature of Parent/Legal GuardianDate

FORM 004: 2015 THE HARRIS FOUNDATION MEDIA RELEASE

I hereby grant permission to The Harris Foundation and/or its associates, assistants, or subcontractors to photograph/film/interview my child, ______.

It is my understanding that photographs/films/interviews or portions thereof will be used for public view (publications, multimedia production, display, advertisement or world-wide web publication for ExxonMobil and The Harris Foundation).

The undersigned agrees that ExxonMobil, The Harris Foundation and its associates may use names, likeness, or biographical information supplied by the undersigned.

I agree to participate in this project without financial remuneration, and I understand that my signature below releases and discharges ExxonMobil, the Harris Foundation, and their agents, officers, volunteers and employees from any future claims and demands, as well as from any liability arising from the use of said photographs/images and interviews.

Name of Child (please print)

Address

City, State, Zip

Area Code & Phone Number

Parent or Legal Guardian (please print)

Signature of Parent or Legal Guardian

Date

2015 EXXONMOBIL BERNARD HARRIS SUMMER SCIENCE CAMP
FORM 005: FIELD TRIP/EXCURSIONS APPROVAL

Dear Parents/Legal Guardians,

Field trips/excursions to the following locations have been scheduled. These trips will be made by bus. The dates and times are listed below. Camp staff will accompany this group and will work with the campers to accomplish the educational objectives of this trip. Campers will be supervised at all times during these field trips/excursions.

DATE / LOCATION / TIME OF DEPARTURE / TIME RETURNING TO UNIVERSITY / METHOD OF TRAVEL

For your child to participate in this Camp activity, it is required that you complete and sign the bottom part of the form and return it today.

Executive Camp Director

This is to certify that has my permission to go on the field trips/excursions listed above with this camp group.

In case of emergency, I may be reached at

(Telephone-home)(Telephone-work)

Signature of Parent/GuardianDate

FORM 006: 2015 AUTHORIZATION TO RELEASE STUDENT CONTACT
INFORMATION FORM

I hereby grant permission to The Harris Foundation and/or its associates, subcontractors and/or university host locations to release the student contact information listed below for my child, ______.

It is my understanding that student contact information will be released, upon request to government representatives for the purpose of program student award recognition. I acknowledge that The Harris Foundation has no control over whether the above-mentioned government representatives may then disclose my child's contact information.

I understand that my signature below releases and discharges ExxonMobil, The Harris Foundation, and their agents, officers, volunteers and employees from any future claims and demands, as well as from any liability arising from the use of said information by government representatives.

Name of Child (please print)

Address

City, State, Zip

Area Code/ Phone Number

Birth date______

Parent or Legal Guardian (please print)

Signature of Parent or Legal Guardian

Date

Host University Camp Name

Name of School in Fall 2015______

City, State, Zip of School in Fall of 2015______

Grade Level in Fall of 2015 ______

2015 EXXONMOBIL BERNARD HARRIS SUMMER SCIENCE CAMP
FORM 007: REQUEST FOR SHORT LEAVE

I hereby request permission for

Please Print: Child’s Name (First, Middle, Last)

to leave campus until

DayDateTime

for the following reason:

I can be reached at

Telephone Number

The above named student will be picked up by

Name (please print)

Relationship to Camper

Signature of parent/legal guardian making request

APPROVED:DATE:

DISAPPROVED:DATE

Released to:

Signature of Person Picking Up Camper

Note: A parent/legal guardian of the camper will be called to verify that the person named has his/her approval to pick up the student. A person other than the parent/legal guardian picking up the camper must show a photo ID.

2015 EXXONMOBIL BERNARD HARRIS SUMMER SCIENCE CAMP
Form 008: Cell Phone Policy

The Harris Foundation (THF) permits student possession and use of cell phones as set forth below, if the campsite programs calls for the use of a cell phone.

Campers are permitted to use cell phones for instructional purposes only, if required, and during times designated for approved THF programs that require the use of a mobile device.

Campers shall not display, use, activate or permit cell phonesto be activated in classrooms, laboratories, and other buildings on campus, on field trips and field excursions, and during recreation time.

Cell phones shall be turned off and kept in his/her backpack when not required for instructional purposes and/or to work on approved THF programs that require the use of a mobile device. When not required, cell phones will be in the possession of the camp administrators.

Campers must obtain permission from an adult in order to use his/her cell phone to call home.

A camper’s cell phone is subject to a search when a camp director, instructor or staff member has reasonable suspicion that the camper has violated or is violating the cell phone policy or using it to take or transmit pictures, store and play video games, text message, harassment or place unauthorized phone calls.

A camper found to be violating the cell phone policy is in violation of the Standard Code of Conduct and will be handled as outlined in the Student Code of Conduct.

The Harris Foundation does not assume responsibility for any lost or stolen cell phones. Please keep your cell phone under direct observation (do not leave unattended) and do not allow others to borrow your cell phone.

******************************************************************************

My child will not bring a cell phone to camp.

My child will bring a cell phone to camp.

Which type?

AndroidiPhoneWindows

Other (please specify)

I have read the Cell Phone Policy with my student.

Student Name (Print)

Student Cell Phone Number

(Area Code) (Phone Number)

Student SignatureDate

Parent/Legal Guardian SignatureDate