GirlsinEngineeringParentalPermissionFormSummer2015

DearParent/Guardian:Congratulations!YourdaughterhasbeenacceptedintotheGirlsinEngineeringsummercamp,forsession1:July13thJuly17th.PleasecompletethispacketandmailitbyMay22nd.Youcanalsoscanandemailtogirlsinengineering@gmail.com.

GirlsinEngineeringBaskinSchoolofEngineering:SOE3UCSC1156HighStreetSantaCruz,CA95064

orFAXitto8314595333Thisprogramiscompletelyfree.Thereisnoapplicationfeeandthereisnofeetoattend.Inaddition,freedailybustransportationwillbeprovidedfromseveralstopsintheSalinasandWatsonvilleareatotheUCSCcampuswherethecampwilltakeplace.Ifyoucannotfindtransportationforyourchildtotheshuttlestopnearestyou,pleasecontactusrightaway.YoucanlearnmoreabouttheGirlsinEngineeringprogramathttp://gie.soe.ucsc.edu/.

STUDENTINFORMATIONName:_____________________________________________________________________School:____________________________________________________________________ Grade(7thor8th):_____________________________________________________________MailingAddress:_____________________________________________________________City/State:______________________________________ZipCode:___________________ParentPhone:_____________________AlternatePhone:____________________________StudentPhone(ifstudenthasacellphone)________________________________________Email:_________________________________________Tshirtsize:____________________TheabovenamedstudenthasmypermissiontoattendGirlsinEngineeringatUCSC.Parentname(print):________________________________________________________Parent/GuardianSignatureRequiredforParticipation:__________________________

STUDENTBEHAVIORAGREEMENTUNIVERSITYOFCALIFORNIA,SANTACRUZ

GirlsinEngineering(GiE)

GiEstudentsmaynotleavetheUCSCcampus,unlessaccompaniedbyGiEstafforfaculty,orparent/guardian.

Students are expected to attend all classes, seminars, lectures, labs, and academic field trips. Students are expected to

participateinallclassactivitiesandcompleteallassignedcoursework.

Thefollowingwillnotbetolerated:

o Denigrationofanotherpersononthebasisofrace,sex,sexualorientation,nationalorigin,ordisability

o Useoffoulorinappropriatelanguage

o Possessionand/orconsumptionofalcoholicbeveragesorillegaldrugs

o Possession of any type of weapon including knives, guns, pellet guns, bb guns, sling shots, water pistols, or any

otherkindofdevicethatcouldinflictinjuriestoyourselforothers

o Violence, harassment, or abuse of any kind. This includes water fights, fistfights, verbal abuse, or any form of

conduct that may cause another individual harm or potential harm or needless feelings of discomfort or

embarrassment.

o Smokingoruseofanyformoftobacco

o Tamperingwithanycomputertechnology,websites,orfire&safetyequipment

o Theftorpropertydamage

StudentswhoabuseordamageUniversitypropertywillbebilledforcostsordamage.

Studentsmustabidebythefollowingdresscode:

o Acceptable clothing includes: walking shorts, jeans & pants, tshirt, blouse or knit shirt, comfortable shoes (tennis

shoes,etc.),sandals,skirts,

o Unacceptable clothing includes: undergarments worn as clothing, clothing with profanity or advertisements for

alcohol or tobacco products, lowcut, backless, strapless, or overlyrevealing clothing. Sunglasses and hats must be

removedinclassorwhenrequested.

Studentsmaynotbringcellphones,CDplayers,iPods,and/orMP3playerstoclassorotheracademicactivities.

Although we will make reasonable efforts to ensure the safety of personal property, GIE is not responsible for damage and/or

lossofanypersonalproperty.

StudentsareexpectedtobeconsideratetoallGIEstaffandpeers.

IunderstandthatifI,__________________________________(PrintParticipantsName)failtoabidebytherulesofconductcitedabove,appropriateconsequenceswillbeenforced.Thiscouldinclude(butisnotlimitedto)adiscussionwithGiEstaff,orremovalfromtheprogram.Aparentorguardianwillbeconsultedwhennecessary. __________________________________________ParticipantSignature __________________________________________SignatureofParent/GuardianofMinor Date

ELECTIVE/VOLUNTARYACTIVITYWAIVERUNIVERSITYOFCALIFORNIA,SANTACRUZ

GirlsinEngineering(GiE)

WaiverofLiability,AssumptionofRisk,andIndemnityAgreement

PrintNameofGiEParticipant ParticipantsDateofBirthWaiver: In consideration of being permitted to participate in any way in Girls in Engineering (GiE), I, for myself, my heirs, personal representatives or assigns, do hereby release, waive, discharge, and covenant not to sue The Regents of the University of California, its officers, employees, and agents from liability from any and all claims including the negligence of The Regents of the University of California, its officers, employees and agents, resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to,participationinGIE.

SignatureofParent/GuardianofMinor Date SignatureofParticipant

DateAssumption of Risks: Participation in GiE carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity to another, but the risks range from 1) minor injuries such as scratches, bruises, and sprains to 2) major injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions to 3) catastrophic injuries including paralysis anddeath.I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in GiE. I hereby assert that my participation is voluntary and that I knowingly assume all suchrisks.Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD The Regents of the University of California HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorneys fees brought as a result of my involvement in GiE and to reimburse themforanysuchexpensesincurred. Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the law of the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal forceandeffect.Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, and indemnity agreement, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signaturetobeacompleteandunconditionalreleaseofallliabilitytothegreatestextentallowedbylaw.

SignatureofParent/GuardianofMinor Date SignatureofParticipantDate

PHOTOGRAPYANDEVALUATIONWAIVERUNIVERSITYOFCALIFORNIA,SANTACRUZ

GirlsinEngineering(GiE)

Please circle yes or no, to tell us if you give permission for the GiE program to include your daughter in the followingcomponentsofouracademicprogram.

YES NO

I give permission for my daughter to participate in a study to determine the effectiveness ofGiEwhichincludesthefollowing:I give permission to allow my daughter to fill out surveys, and participate in interviews to share her perceptions of the benefits and quality of the GiE program. My child can discontinueparticipationinthesesurveysandinterviewsatanytime.I give permission to GiE to obtain my daughters school records (e.g., courses taken, grades, and test scores through twelfth grade) which will be maintained in electronic files. Thisinformationwillbemaintainedwithstrictconfidentiality.I understand that some of the information may result in publication, but that all responses will be treated as confidential and will be reported as a group. Details about individuals or familieswillnotbedisclosed.

YES NO I give permission to use my daughter's/my photograph(s), essays, quotes, or coursework in promotional materials and publicity efforts. I understand that the item(s) may be used in a publication, print ad, electronic media (e.g. Internet), or other form of promotion. I release the university, the photographer, their office, employees, agents, and designees from liability for any violation of any personal or proprietary right I may have in connection with such use. Please note that indicating No will also result in the removal ofyourdaughterspicturefromGiEpublicationsintendedforthegirlstokeep.

__________________________________________________PrintNameofGiEparticipant __________________________________________________ PrintNameofParent/GuardianofMinor __________________________________________________ SignatureofParent/GuardianofMinor Date

MEDICALRELEASEINFORMATIONUNIVERSITYOFCALIFORNIA,SANTACRUZ

GirlsinEngineering(GiE)

Pleaseprovidetheinformationoftwoindividuals(suchasafriendorrelative)thatcanactasanemergencycontactforyourchildifyoucannotbereached. Name: _ PhoneNumber:( )

Address: _ City: ZipCode:

Relationshiptostudent: Name: _ PhoneNumber( )

Address: _ City: ZipCode:

Relationshiptostudent: Isyourchildcoveredbyamedicalplan? Yes NoIfyes,nameofplan/insurance: _ PlanID#:

DoctorsName: Phone: Isyourchildonanymedication?Yes No

Ifyes,listthenamesofthemedication:

Doesyourchildhaveanyallergiesoralifethreateningconditionweshouldbeawareof? Yes NoIfyes,providedetails: Yes NoIauthorizemychildtobegivennonprescriptionmedicinesuponherrequest(example:Alka

Seltzer,PeptoBismol,Ibuprofen,etc.) PermissionforEmergencyTreatmentI understand that the GiE staff will try to contact the parent(s)/guardian(s) in case of illness or injury. If deemed necessary, based on the judgment of staff and authorized personnel, I give permission for my child to be taken by paramedics or ambulance to a hospital, and for a physician to take the action necessary to meet the emergency. I understand that I am responsible for any costs incurred. If I am unable to pick up my child in the event of an emergency, my child may be released totheemergencycontactIhaveprovidedtoGiE. _____________initials.Iherebygrantpermissionformychild, ,toparticipateintheGirlsinEngineeringprogramandIherebyacknowledgethatatthepresenttime,mychildisingoodphysicalhealth.__________________________________________________________________________________________ PrintNameofParent/GuardianofMinor SignatureofParent/GuardianofMinor Date

TRANSPORTATIONCONSENTFORMUNIVERSITYOFCALIFORNIA,SANTACRUZ

GirlsinEngineering(GiE)GiEhascontractedUCSCTransportationServicestoprovidetransportationtoandfromtheprogramvenueforthedurationoftheprogram.Thebusstopsandtimesaresubjecttochangebasedondemandfromthestudents.

No,mychildwillnotusethetransportation

Yes,mychildwillusethetransportationprovided.(Pleasecirclethelocationbelowwhereyourchildwillbepickedupanddroppedoff.)

MorningRoute AfternoonRoute

Stop1 ChualarSchool24285LincolnStreet,Chualar,CALeaves7:15am

Leave UCSCJackBaskinEngineeringBuildingClassendsat3:00pm

Stop2 SalinasElSausalMiddleSchool

1155EastAlisalStreet,Salinas,CAInfrontofschoolintheGreenParkingZoneLeaves7:35am

Stop1 CapitolaNewBrightonMiddleSchool250WashburnAve.,Capitola,CA95010Leaves3:30pm

Stop3 CastrovilleCommunityCenter

CornerofPomberSt.andPrestonSt.Leaves8:00am

Stop2 WatsonvilleCesarChavezMiddleSchool(Busstopsinfrontofthegym)440ArthurRdWatsonville,CA95076Leaves3:45pm

Stop4 WatsonvilleCesarChavezMiddleSchool

(Busstopsinfrontofthegym)440ArthurRdWatsonville,CA95076Leaves8:20am

Stop3 CastrovilleCommunityCenterCornerofPomberSt.andPrestonSt.Leaves4:00pm

Stop5 CapitolaNewBrightonMiddleSchool

250WashburnAve.,Capitola,CA95010Leaves8:40am

Stop4 SalinasElSausalMiddleSchool1155EastAlisalStreet,Salinas,CAInfrontofschoolintheGreenParkingZoneLeaves4:20pm

Arrive UCSCJackBaskinEngineeringBuilding

Classstartsat9:00am Stop5 ChualarSchool

24285LincolnStreet,Chualar,CALeaves4:40pm

Iherebygrantpermissionformychild,torideontheshuttlecontractedbyGirlsinEngineeringprogramforthedurationoftheprogram.Ifyoucannotfindtransportationforyourchildtotheshuttlestopnearestyou,pleasecontactus.

__________________________________________________ PrintNameofParent/Guardian __________________________________________________ SignatureofParent/Guardian Date