COSMOS 2017 Accepted Student Packet Checklist
Cluster 9
Please make sure all forms are filled out completely and signed by the student and a parent/guardian as required.
Waivers:
UCSD Online Services Agreement
Waiver of Liability, Academic and Transportation Agreement
Evaluation Consent/Media Release Waiver
Swim Test Certification
Family Weekend Departure Form
Confidential Health History Form
Health Facility Information
UCSD Cosmos Program Student Code of Conduct Certification
Academic Field Trip/Field Work & Weekend Excursion Waiver
Minors in the Lab Form
Volunteer Opportunities Waivers (sign both so students can decide to participate in either event; other
activities will be provided for those who do not wish to participate in volunteer opportunities)
Additional Items:
Check or Money Order (payable to “UC Regents” and indicate your child’s name and application ID on the
memo line). Credit card payment is available by logging into the student’s online application and selecting the
“Online Payment” tab. A 2.5% service fee will be added to all online payments.
Medical Insurance Card – copy, front and back
Review “What to Bring Checklist” – don’t need to mail in
Mail all waivers to:
Mail all checks to:
COSMOS at UC San Diego
Jacobs School of Engineering
9500 Gilman Drive #0429
La Jolla, CA 92093-0429
COSMOS- Statewide
Cashier’s Office
University of California
PO Box 989062
West Sacramento, CA 95798-9062
COSMOS at UC SAN DIEGO
CALIFORNIA STATE SUMMER SCHOOL FOR MATHEMATICS & SCIENCE
IRWIN AND JOAN JACOBS SCHOOL OF ENGINEERING
9500 GILMAN DRIVE, M/C 0429
LA JOLLA, CALIFORNIA 92093-0429
Tel: 858-822-4361; Fax: 858-822-3903
E-MAIL: COSMOS@ UCSD.EDU
UCSD Online Services Agreement
COSMOS students are authorized to use the University’s Internet/online services in accordance with the following
obligations and responsibilities:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Users are responsible for proper use of online accounts at all times. Users shall keep private personal account numbers,
addresses, and telephone numbers. They shall use the system responsibly.
The Internet shall be used for educational purposes only. Commercial, political and/or personal use is strictly prohibited. The
University reserves the right to monitor online communication for improper use.
Users shall not use the system to encourage the use of drugs, alcohol, or tobacco, nor shall they promote unethical practices or
any activity by law or University policy.
Users shall not transmit or access material that is threatening, obscene, disruptive, or sexually explicit nor material that could be
construed as harassment or disparagement of others based on race, national origin, sex, sexual orientation, age, disability, or
political belief.
Materials obtained or copied on the Internet may be subject to copyright laws, which govern the making of reproductions of
copyrighted works. A work protected by copyright may not be copied without permission of the copyright owner unless the
proposed use falls within the definition of “fair use.” Violation of copyright laws may subject user to an action for damages
and/or injunction.
Users shall not read others’ mail or files, they shall not attempt to interfere with another users’ ability to send or review electronic
mail, nor shall they attempt to delete, copy, modify or forge other users’ mail.
Users are expected to keep messages brief and use appropriate language.
Users shall report any security problems or misuse of the network to any COSMOS Staff.
The Internet contains material that may be considered harmful. The University will not knowingly allow the use of the Internet for
access of harmful matter. Because the University is a public place shared by students and staff of all ages, staff reserves the
right to end Internet sessions when such material is displayed. The University maintains all Internet stations.
I understand and will abide by the provisions and conditions on this contract. I understand that any violation of the above provisions
may result in disciplinary actions, the revoking of my technology access privileges, dismissal from the program, and/or appropriate
legal action.
I plan to bring my personal laptop computer to COSMOS*:
_____________________________
Student Name (Please Print)
Yes
No
__________________________________
Student Signature
____________________
Date
I have read this contract and understand that Internet privileges are intended for education purposes. I understand that it is
impossible for the University of California, San Diego to restrict access to all controversial materials, and I will not hold the University
responsible for material acquired on the network. I agree that my son/daughter’s inappropriate use of the University’s technology my
result in disciplinary action, the loss of technology privileges, dismissal from the program, and/or appropriate legal action. I hereby
give my permission for my student to access information utilizing the University network and Internet gateway.
______________________________
Parent/Guardian Name (Please Print)
__________________________________
Parent/Guardian (Signature)
____________________
Date
*Students are not required to bring computers and will have access to facilities during the duration of the program. The above
signatures also indicate that signers will not hold UC San Diego or COSMOS responsible for loss or damage to personal
computers. Signers fully accept the inherent risk of bringing private property to campus.
COSMOS at UC San Diego
California State Summer School for Mathematics & Science
Irwin and Joan Jacobs School of Engineering
9500 Gilman Drive MC 0429
La Jolla, California 92093-0429
Tel: 858-822-4361 Fax: 858-822-3903
Waiver of Liability, Assumption of Risk, Indemnity Agreement
Academic & Transportation Waiver: In the consideration of being permitted to participate in any way in
Academic Programs and transportation for all Academic programs from 07/09/17 – 08/05/17, including all
academic and residential living activities including laboratories, classrooms, sports, swimming, social, and offcampus events. Transportation includes 7 passenger vans, chartered buses, and UCSD/staff vehicles.
Hereinafter called “The Activity,” 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 negligence of the Regents of the University of
California, its officers, employees and agents, resulting in personal injury, accidents or illness (including death),
and property loss arising from, but not limited to, participation in The Activity.
Assumption of Risks: Participation in The Activity 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, 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 and
death.
I have read the previous paragraph and I know, understand, and appreciate these and other risks that are
inherent in The Activity. I hereby assert that my participation is voluntary and I knowingly assume all such risks.
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, suit, procedures, costs, expenses, damages, and
liabilities, including attorney’s fees brought as a result of my involvement in The Activity and to reimburse them
for any such expenses incurred.
Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of risks
agreement is intended to be as broad an 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 force
and effect.
Acknowledgement 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 signature to be a
complete and unconditional release of liability to the greatest extent allowed by the law.
_____________________________
Student Name (Please Print)
__________________________________
Student Signature
____________________
Date
______________________________
Parent/Guardian Name (Please Print)
__________________________________
Parent/Guardian Signature
____________________
Date
Participant’s age (if a minor): ____
COSMOS at UC San Diego
California State Summer School for Mathematics & Science
Irwin and Joan Jacobs School of Engineering
9500 Gilman Drive MC 0429
La Jolla, California 92093-0429
Tel: 858-822-4361 Fax: 858-822-3903
Evaluation Consent
The University intends to conduct a program evaluation of this year’s COSMOS Program to learn about students
experiences in COSMOS and the impact he/she thinks it had. We use this information to make modifications and
improvements in future programs and to better understand the program effects on its participants. Your evaluative
comments will help ensure that future participants will have a positive experience and benefit from the program to
the highest degree possible.
Students will be asked to complete a questionnaire at the beginning of the program and another one at the
end. Each questionnaire will take about 30 minutes and there may be cluster specific questions included. All
information gathered during this process will be confidential, there are no risks to completing the evaluation.
Only program staff involved in evaluating the program will have access to the survey and interview results.
Name of COSMOS Participant (please print): ________________________________________________________________
Yes
No
My student has permission to participate in the evaluation of COSMOS
Student Signature____________________________________________
Date _________________
Parent/Guardian Signature ______________________________________ Date _________________
Media Release Waiver
We hereby authorize the Regents of the University of California and their appointed agents to photograph,
videotape, audio record, televise, duplicate and/or transfer to present or future technology for the purposes of
COSMOS program public relations and marketing,
________________________________(student’s name) as a participant in/alumnus of the COSMOS program.
To promote the COSMOS program, we agree that the Regents of the University of California its authorized agents,
employees and assignees may use the photographs, videotapes, and/or audio recordings prepared there from, to
produce, exhibit, publish, or distribute in any positive manner as they deem fit. No compensation will be paid for this
use.
I understand that my student’s name, hometown or country, honors, photograph, and partial or full sections of their
COSMOS essays may be used or be considered for use, for future COSMOS information items, including news
releases.
Student Signature ___________________________________________ Date _________________
Parent/Guardian Signature _____________________________________ Date _________________
SWIM TEST CERTIFICATION
Students in COSMOS have field trips and activities that includes the beach. To participate in the water activities or
swim in the ocean during this field trip or residential activities, students MUST pass the swim test certification and have
parental consent to participate. Students in COSMOS who do not complete the Swim Test Certification will NOT be
allowed to participate in any water activities.
Students must take the following swim-test and have a Certified Lifeguard or American Red Cross Water Safety
Instructor attest to completion of this test by signing the form below. These tests can be taken at any pool where a
Lifeguard or Water Safety Instructor is present.
•
•
200 yards continuous swim, any stroke
5 minutes of continuous treading of water
COSMOS Participant Name ________________________________________________________________
Yes, I would like to participate in water activities at COSMOS. (Please complete certification
below)
No, I will NOT be participating in ANY water activities at COSMOS, including swimming at the
beach.
Certification
I, ________________________________, certify that _______________________________________ has completed 200
Name of Guard or Instructor
Name of COSMOS Participant
yards of continuous swimming, followed by 5 minutes of treading water. This test of swimming ability was given at
___________________________________________ on ________________.
Name of Swim Test Site
Date of Test
I am currently certified as a lifeguard on American Red Cross Water Safety Instructor or comparable instructor
certification. My certification expires on __________________________.
_________________________________________________ ____________________________________
Signature of Guard or Instructor
Date
________________________________________________
Signature of COSMOS Applicant
____________________________________
Date
* I hereby consent that my student may participate in ocean swimming and water activities during COSMOS
field trips.
_____________________________________________
____________________________________
Signature of Parent or Guardian
Date of Consent
_____________________________________________
____________________________________
Signature of Parent or Guardian
Date of Consent
If one parent/guardian is legally responsible for the student then only one parent/guardian signature is required.
COSMOS at UC San Diego
California State Summer School for Mathematics & Science
Irwin and Joan Jacobs School of Engineering
9500 Gilman Drive MC 0429
La Jolla, California 92093-0429
Tel: 858-822-4361 Fax: 858-822-3903
Family Weekend Departure Form
Students may leave the COSMOS program as noted below for Family Weekend. Many students remain at COSMOS,
and supervision and activities are planned for those students. Students WILL NOT be allowed to leave campus without
ADVANCED written permission from a parent/guardian. Prior to departure and upon return, students MUST be signed
in/out by the person listed below with a COSMOS staff member at the Eleanor Roosevelt College Residential Halls.
This policy is for the safety of our students.
If you are unsure, complete the form as if the student will be departing. Students will be asked to confirm their intention
closer to the weekend date. Having a completed form on file allows the student to choose.
All students MUST be back on campus by 5:00pm Sunday, July 23.
 My student will be picked-up on Friday, July 21 and return on Sunday, July 23
 My student will not be participating in Family Weekend
Student Name
_______________________________________
Student Contact Number (e.g. 858-822-4361): _______________________________________
Cluster Name or Number:
_______________________________________
DEPARTURE INFORMATION
Person(s) picking-up student:
(must be over 18 – IDs required)
Friday, July 21, 2017
Pick-up Between 5-9pm
_______________________________________
Relationship of above person(s) to student: _______________________________________
Contact Number (e.g. 858-822-4361):
_______________________________________
Sunday, July 23, 2017
Drop-off between 2:00-5:00pm
RETURN INFORMATION
Person(s) dropping-off student:
(if different from above)
_______________________________________
Relationship of above person(s) to student:
_______________________________________
Contact Number (e.g. 858-822-4361):
_______________________________________
I understand the procedures and check-in/check-out times for Family Weekend and verify that all of the above
information is correct.
______________________________
Parent/Guardian Name (Please Print)
__________________________________
Parent/Guardian Signature
____________________
Date
COSMOS at UC San Diego
California State Summer School for Mathematics & Science
Irwin and Joan Jacobs School of Engineering
9500 Gilman Drive MC 0429
La Jolla, California 92093-0429
Tel: 858-822-4361 Fax: 858-822-3903
Confidential Health History Form (1 of 2)
Student Name
Last
PRINT
First
Gender  M  F
PRINT
DOB:
MM/DD/YYYY
Cluster # and title:
Parent/guardian who holds insurance coverage for student:
DOB: _______________
 Private Medical Insurance  Kaiser  Medi-Cal  None  Other
 PLEASE provide a copy of the front and back of the insurance and/or prescription card that covers the student
GENERAL HEALTH
My general health is:
 Excellent  Good  Fair  Poor
Height:
Weight: lbs.
Eye Color:
Hair Color:
List any recent or continuing health problems:
List any physical or learning disabilities:
Are you currently under the care of a doctor or other healthcare professional?
 Yes
 No
If yes, please specify for what condition(s):
MEDICAL HISTORY
Please circle the appropriate answer for each of the following questions as it pertains to the COSMOS student:
OVER-THE-COUNTER MEDICATIONS:
Okay to dispense at students request?
(i.e. Tylenol, Dayquil, Nyquil, Robitussin, Advil,
Benadryl, Pepto Bismol, Cough Drops, etc)
FOOD (please circle all that apply):
Vegetarian Vegan Allergies
Specify allergies________________________
YES
NO
YES
NO
Diabetes?
If yes, do you use insulin and how often?
YES
YES
NO
NO
Do you carry an epinephrine pen?
Bee Sting Kit?
Allergic to insect bites?
YES
YES
YES
NO
NO
NO
YES
YES
NO
NO
YES
NO
YES
YES
NO
NO
Dietary Restrictions______________________
NOTE: If YES, an additional Medical Form needed
for accommodations. Contact [email protected]
for form.
Restrictions______________________________
Allergic to any medications?
If yes, medications and symptoms:
YES
NO
Knee, hip, ankle, shoulder, arm or back
injuries/operations? If yes, date and type of injury:
YES
NO
_______________________________________
______________________________________
Prosthetic joints or devices
If yes, list_____________________________
YES
NO
Respiratory problems? Asthma?
Do you carry an inhaler?
Other (e.g. crutches)______________________
YES
NO
_____________________________________
Cultural/Religious Restrictions?
Food?
Surgery/Hospitalization? List type and year:
YES
Neurological problems?
Epilepsy?
Pacemaker?
YES
YES
YES
NO
NO
NO
NO
Other?
Contact lenses or eyeglasses
Hearing Aids:  Both  Right  Left
Confidential Health History Form (2 of 2)
MEDICATIONS – Parent acknowledges that student is required to store prescription and over-the-counter medications in
original containers with written instructions, is responsible to self-administer dosage according to instructions, and not share
medications with other students.
ARE YOU TAKING ANY MEDICATIONS?  YES  NO
If yes, please specify below:
AUTHORIZATION FOR TREATMENT
Instructions: In the event of an emergency, UC San Diego COSMOS will make every effort to reach the
parent(s)/guardian(s) before using the authorization below. However, in the case of an emergency, your authorization may
assist in obtaining immediate and necessary medical care for your child or dependent.
Statement: By signing this authorization, I hereby authorize the University of California's employees, faculty, agents or other
designated official to act on my behalf and authorize such emergency treatment for my child/dependent to secure whatever
treatment is deemed necessary.
The authority granted by this authorization includes the authority to consent to any x-ray examination, anesthetic, medical, or
surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be
rendered by a physician and/or surgeon. This authority also extends to any x-ray examination, anesthetic, dental, or surgical
diagnosis or treatment and hospital care by a dentist.
I understand that I am responsible for any and all charges incurred including transportation by ambulance. If I am unable to
pick up my child/dependent in the event of an emergency, my child/dependent may be released to the emergency contact
listed below. This authorization is valid until August 5, 2017.
Mother’s Name:
Mother’s Day phone:
Mother’s Evening phone:
Father’s Name:
Father’s Day phone:
Father’s Evening phone:
Emergency Contact (other than parent/guardian):
Day phone:
Evening phone:
AUTHORIZATION FOR USE OR DISCLOSURE OF MEDICAL INFORMATION
I hereby authorize UC San Diego COSMOS to release the information included on this form, including all pages of this
Confidential Health History form, and any additional medical information submitted to UC San Diego COSMOS (including
verbal, electronic, and supplemental pages) or to the University of California's employees, faculty, agents or other designated
official to medical and/or psychological professionals, agents or other designated personnel. I understand that this
information will be used for the purpose of protecting my child’s/dependent’s health during the period of his/her participation
in the program identified on the form, including, but not limited to providing information for the purpose of medical treatment in
the case of medical urgency while participating in COSMOS.
 I HAVE ENCLOSED A COPY OF BOTH SIDES OF MY MEDICAL INSURANCE CARD and understand that this
information will be used for the purpose of protecting my child’s/dependent’s health during the period of his/her participation
in the program identified on the form, including, but not limited to providing information for the purpose of medical treatment in
the case of medical urgency while participating in COSMOS. This authorization is valid until August 5, 2017.
_____________________________
Student Name (Please Print)
__________________________________
Student Signature
____________________
Date
______________________________
__________________________________
____________________
Parent/Guardian Name (Please Print)
Parent/Guardian Signature
Date
COSMOS at UC San Diego
California State Summer School for Mathematics & Science
Irwin and Joan Jacobs School of Engineering
9500 Gilman Drive MC 0429
La Jolla, California 92093-0429
Tel: 858-822-4361 Fax: 858-822-3903
Health Facility Information Form
In the event a COSMOS participant needs medical attention, these are the available health care providers. Please check into these
providers if there are any concerns as to whether your medical insurance will cover expenses incurred during a visit. Please indicate your
preference on where your child should go on the form below. In a non-emergency situation, your preference in health care provider will be
taken into consideration. Please indicate your choices:
In addition to filling out this form, please complete the Confidential Health History Form and be sure to enclose a photocopy of the front and
back of the insurance card covering the student.
Health Facilities
My child can
visit this clinic
If possible
please take my
child to another
provider
My child can
visit this clinic
If possible
please take my
child to another
provider
My child can
visit this clinic
If possible
please take my
child to another
provider
Partners Urgent Care - UTC
4085 Governer Dr. San Diego, CA 92122
858-888-7800
Hours: M-F 8am-8pm
Distance: 5 minutes
Fees: Please Call
Rady Children’s Urgent Care
4305 University Avenue, Suite 150 San Diego, CA 92105
619-280-2905
Hours: M-F 4-10pm S-Su 1pm-10pm
Distance: 25 minutes
Fees: Please Call
Kaiser
Otay Mesa Urgent Care 4650 Palm Ave. San Diego, CA 92154
San Marcos Urgent Care 400 Craven Rd. San Marcos, CA 92078
800-290-5000
Hours: M-F10am-8pm S-Su 9am-5pm
Distance: 30-45 minutes
Fees: Please Call
 PLEASE provide your student with enough money to pay copays and/or prescriptions in the case that the
student is taken to a Health Care Facility.
Permission for Emergency Treatment
I understand that the COSMOS Staff will try to contact the parent(s)/guardian(s) in case of illness or injury. In case of illness or injury, and
when in the judgement of staff, emergency attention is warranted, I authorize the staff to seek medical attention for my child. If deemed
necessary, I give permission for my child to be taken by paramedics or ambulance to a hospital and for a physician to take whatever action
is necessary to meet the emergency. I understand that I am responsible for any charges incurred. If I am unable to pick up my child in the
event of an emergency, my child may be released to the emergency contact I have provided to COSMOS.
_____________________________
Student Name (Please Print)
__________________________________
Student Signature
____________________
Date
______________________________
__________________________________
____________________
Parent/Guardian Name (Please Print)
Parent/Guardian Signature
Date
UCSD COSMOS Program Student Code of Conduct Certification
ALL STUDENTS, please carefully READ, SIGN and MAIL this Certification page with your additional required forms,
waivers and tuition payment to the address below on or before June 2, 2017 deadline. Keep the remaining portion of the
COSMOS Student Code of Conduct for your records and as a reference.
COSMOS at UC San Diego
Jacobs School of Engineering
9500 Gilman Drive #0429
La Jolla, CA 92093-0429
Email: [email protected]
Phone: (858) 822-4361
By signing this certification, ______________________________________, as the parent(s)/guardian(s) of
Print parent/guardian’s full name
______________________________________, certify that we have read, understand, and agree with the
Print student’s full name
terms and conditions of the COSMOS Student Code of Conduct, the Judicial Review process, all Student/Parent
Handbook sections, and other publications incorporated herein by reference. Furthermore, we understand that failure to abide
by all rules of conduct cited above will result in disciplinary action outlined under the Judicial Review section.
TUITION REFUND POLICY
Acknowledgement/Understanding of the COSMOS Tuition Refund Policy: All refund requests must be submitted in
writing to the COSMOS Program Manager by U.S. mail, e-mail, or fax. In case you are admitted from a waitlist, a one-week
period will be given to decide on acceptance and payment of non-refundable deposit. Tuition & Refund Policy still apply,
unless Tuition Payment deadline has passed. Refund payments shall be issued to the party who paid the tuition payment. A
refund will take up to 90 days to process. The UCSD COSMOS refund schedule is as follows:
• Cancellation request received on or before June 2nd, 2017: 100% of tuition (less $200 non-refundable deposit)
• Cancellation request received on or before June 16th, 2017: 50% of tuition (less $200 non-refundable deposit)
• Cancellation request received after June 16th, 2017: NO REFUND
• Dismissal or voluntary departure from COSMOS program at any time: NO REFUND
If you have been awarded Financial Assistance
It is understood that by accepting financial assistance to attend the COSMOS program, I am making a commitment to complete
the full four weeks of the program. I acknowledge that financial assistance to attend COSMOS is provided by a private donor to
ensure that all committed California students will have the opportunity to pursue their academic interests.
ALL STUDENTS MUST SIGN. If only one parent/guardian is legally responsible for the student, then only one
parent/guardian signature is required.
Parent/Legal Guardian Signature __________________________________ Date _______________
Parent/Legal Guardian Signature __________________________________ Date _______________
Student Participant Signature ______________________________________ Date _______________
COSMOS at UC San Diego
California State Summer School for Mathematics & Science
Irwin and Joan Jacobs School of Engineering
9500 Gilman Drive MC 0429
La Jolla, California 92093-0429
Tel: 858-822-4361 Fax: 858-822-3903
Academic Field Trip/ Field Work & Weekend Excursion Waiver
As stated in California Education Code Section 35330, I understand that I hold harmless the Regents of the University of
California, its officers, employees, and agents, as well as all other participating school districts, their offices, employees,
and agents from any and all claims including the negligence of the Regents of the University of California, its
officers, employees, and agents in connection with participation in any and all Academic Field Trip/Field Work &
Weekend Excursions offered through the COSMOS Summer Program.
In the event of injury or illness, I hereby consent to x-ray, examination, anesthetic, medical, dental or surgical diagnosis
or emergency treatment and hospital care from a licensed physician and/or surgeon as deemed necessary for the
participant’s safety and welfare. I accept full responsibility for resulting medical expenses.
I understand that as a participant of the COSMOS Program that my student will participate in academic field trip/field work
activities, trips off-campus, and weekend excursions. I understand and give my permission for my student to participate in
any and all possible field trip activities listed on this waiver. Further, I also understand that my student will be transported to
these activities via 7-8 passenger vans, UCSD shuttle, commercial bus, school bus companies, and/or university vehicle.
I understand and attest that my student will abide by all rules and regulations governing conduct during these activities.
Any violation of these rules may result in my student’s dismissal, at my expense, including forfeiture of fees and
transportation to return home.
Possible activities include:
♦ San Diego Supercomputer Center
♦ Stephen Birch Aquarium
♦ Scripps Institution of Oceanography
♦ Balboa Park and Museums
♦ San Diego Zoo
♦ Shopping malls, movie theaters, ice cream shops, etc
♦ Downtown La Jolla
♦ Afternoons/evenings at the UCSD Recreation Hall, Swimming Pool, RIMAC Center
♦ Recreational activities such as volleyball, basketball, baseball, Frisbee, etc
♦ Tours of UCSD School of Medicine and other campus sites of interest
While some of the above listed activities may NOT occur, they are listed to provide you with advance information about the
types of field trips/field work and weekend excursions currently being considered and/or planned for COSMOS participants.
Please feel free to keep the list as a reference, but return the signed portion with the rest of your waivers.
If there are any activities (listed above or otherwise) and/or experiences that you DO NOT wish your student to
participate in, please indicate this in the space provided below:
Student Name (Please Print)
Student Signature
Date
I am the parent/guardian of the student listed above and I am signing the Waiver/Release on behalf of said student and
authorizing participation in any and all COSMOS academic field trips/field work and weekend excursions with the exception
of those I have indicated above.
Parent/Guardian Name (Please Print)
Parent/Guardian Signature
Date
Proposed Project Checklist for Minors
Performing Research in Laboratories
University of California, San Diego
Minor's name: -----------------------­
Date of birth:-----------------------­
Supervisor: Dr. Mauricio de Oliveira; Dr. Shlomo Dubnov
Principal Investigator: Dr. Mauricio de Oliveira
Time frame of research project: July 9 - August 5, 2017
CJ Check here if this minor will be participating in a research laboratory project
V
Check here if this minor will be participating in a classroom or educational outreach
program
Project summary and types of experiments to be performed (attach a symptomatology
oaae for anv biohazards): Cluster 9 -Music and Technoloav
Students will use electronic circuit components and microprocessors.
Approved exceptions to guidelines (require approval of appropriate Committee(s)):
Signatures (must be completed prior to beginning work):
Minor:
PI:
-----------
Parent or
Guardian: --------------
/{�/
Supervisor:
EH&S Officer(s) below:
CSO:
BSO:
RSO:
(If different than
PI)
Name of Group:_______________________________
Cleanup Location:_________________________________
ADOPT-A-BEACH WAIVER OF LIABILITY AND EXPRESS ASSUMPTION OF RISK
(PLEASE READ CAREFULLY)
I, ______________________, HEREBY CERTIFY THAT I AM AWARE OF THE INHERENT HAZARDS OF A BEACH CLEANUP.
I agree as follows: 1. I am volunteering my services for the Adopt-A-Beach program ("the Event") on a voluntary basis without
anticipation of payment of any kind; 2. I will perform assigned tasks that are within my physical capability to the best of my ability, and
I will not undertake tasks that are beyond my ability; 3. I am familiar with the safe operation and use of equipment and tools that I may
utilize in connection with this volunteer activity, and I will not undertake to use any equipment or tools with which I am unfamiliar or do
not know how to operate safely; 4. I acknowledge that I have received and read appropriate instruction regarding this Event, including
appropriate safety and emergency procedures, and that I fully understand those instructions and that I agree, after proper inspection, to use
only the supplies, tools and equipment provided by the Event organizers; 5. I will perform only those tasks assigned, observe all safety
rules, and use care in the performance of my assignments; 6. I specifically acknowledge that I am engaging in this activity as a volunteer,
at my own request and risk, and not as a State of California or Foundation employee, agent, official, officer or representative, and further
acknowledge that I am not entitled to any compensation, benefit or insurance coverage from the State of California, the Department of
Parks and Recreation, the California Coastal Commission, the California State Parks Foundation, I Love A Clean San Diego or any Event
promoter or sponsor, nor will I make any such claim.
I understand and agree that neither the State of California, California Coastal Commission, California Department of Parks and
Recreation, California State Parks Foundation, I Love A Clean San Diego, nor any other organizers or promoters or sponsors or property
owners involved in this event, nor any of their respective employees, officers, agents or assigns, (hereinafter collectively referred to as
"Released Parties"), may be held liable or responsible in any way for any injury, death or other damages to me or my family, heirs, or
assigns that may occur as a result of my participation in this activity, or as a result of product liability or the negligence of any party,
including Released Parties, whether passive or active.
I understand that cleaning up beaches , rivers and waterfront areas involves certain inherent risks, including but not limited to,
the risks of possible injury, infection or loss of life as a result of contact with needles, condoms, metal objects, burning embers or other
hazardous materials found on the beach, or from over-exertion or environmental conditions. Despite these risks, I still choose to proceed
in such activity. I know of no physical limitation which should keep me from undertaking the activities associated with this Event. In
Consideration for being allowed to participate in this activity, I hereby personally assume all risks in connection with the Event for any
harm, injury or damage that may befall me as a participant, including all risks connected therewith, whether foreseen or unforeseen. I
further save and hold harmless said activity and Released Parties from any claim or lawsuit for personal injury, property damage, or
wrongful death, by me, my family, estate, heirs, or assigns, arising out of participation in this activity, including both claims arising
during the activity and after I complete the activity.
If I should become injured while participating in the Event, I authorize any physician or surgeon licensed in the State of
California to perform emergency or surgical treatment as in his or her sole judgment may be necessary. I further declare that I am
eighteen and legally competent to sign this liability release, or that I have acquired the written consent of my parent or guardian. I
understand that the terms herein are contractual and not a mere recital, that this instrument is legally binding, and that I have signed this
document of my own free act.
BY THIS INSTRUMENT I DO HEREBY EXEMPT AND RELEASE ALL "RELEASED PARTIES," AS DEFINED ABOVE,
FROM ALL LIABILITY OR RESPONSIBILITY WHATSOEVER FOR PERSONAL INJURY, PROPERTY DAMAGE OR
WRONGFUL DEATH, HOWEVER CAUSED, INCLUDING NEGLIGENCE OF THE RELEASED PARTIES, WHETHER PASSIVE
OR ACTIVE.
I HAVE FULLY INFORMED MYSELF OF THE CONTENTS OF THIS LIABILITY RELEASE AND ASSUMPTION OF
RISK BY READING IT BEFORE I SIGNED IT ON BEHALF OF MYSELF AND MY HEIRS.
___________________________________ ____________
Spelling of Participant's Name
Date
______________________________
Street Address
___________________________________
Signature of Participant
______________________________
City, State, Zip
____________________
Phone
IF PARTICIPANT IS UNDER 18, THE PARENT(S) (OR GUARDIAN(S), IF ANY) MUST SIGN.
The above participant has my permission to participate in the Adopt-A-Beach program. I have read and agree to the provisions
stated above. I know of no health limitations which may restrict this volunteer's participation in this activity.
___________________________________
Signature of Parent(s) or Legal Guardian(s)
___________
Date
___________________________________
Signature of Parent(s) or Legal Guardian(s)
___________
Date
______________________________
______________________________
Address
______________________________
______________________________
Address
____________________
Phone
____________________
Phone
Hello,
Thank you for volunteering with Feeding America San Diego! Last year, more than 13,000 volunteers
helped Feeding America San Diego to distribute over 22 million pounds of food to San Diegans facing
hunger. All projects are geared around bagging, boxing, and distributing food that will be distributed to
over 60,000 people each week- and we couldn’t do it without you!
Important reminders:
•Close-toed shoes are required. Tennis shoes or running shoes work great!
•The distribution center is neither cooled nor heated – we urge you to dress accordingly.
•Wear proper work clothes that you do not mind getting dirty.
•Eating or drinking is permitted in the break room only. (Closed bottles of water are allowed in the
Distribution Center.)
•Leave valuables in your vehicle or at home. No jewelry.
• Bringing work gloves is recommended, but not required.
•Sign in on the iPad and complete a name tag before entering warehouse.
Youth Volunteer Reminders:
•Children under 6 years will not be allowed in the warehouse.
•Children under 6 years will have to remain in the volunteer center with a chaperone at all times.
•Volunteers under the age of 16 must have an adult volunteer with them and all volunteers under the age
of 18 must turn in a paper waiver signed by their parent or guardian in order to volunteer.
•Our required chaperone ratio is 1 adult to every 5 volunteers ages 6 through 13 and 1 adult to every 10
volunteers ages 14- 16.
•We require a separate volunteer waiver per youth volunteer.
Directions to Feeding America San Diego:
9455 Waples Street, Suite 135 San Diego 92121.
From the 805 Freeway, take exit 27A for Mira Mesa Blvd/Vista Sorrento Pkwy. Drive east on Mira Mesa
Blvd. Turn right at Huennekens Street. Take the 1st right onto Waples Street. Drive to the end of the culde-sac and turn left and make and immediate left in the parking lot. Turn right at the second warehouse
building and Feeding America San Diego is suite number 135.
From the 15 Freeway, exit 16 Mira Mesa Blvd. Drive west on Mira Mesa Blvd. Turn left at Huennekens
Street. Take the 1st right onto Waples Street. Drive to the end of the cul-de-sac and turn left and make and
immediate left in the parking lot. Turn right at the second warehouse building and Feeding America San
Diego is suite number 135.
There is a FASD sign above our main entrance door. If you see our FASD trucks, you are at the backside
of our building. Please drive around to the front entrance, unless otherwise indicated on your volunteer
shift details.
For more information about Feeding America San Diego and other ways to make an impact visit
www.feedingamericasd.org. Thank you for your volunteer action and support!
Teresa Dale,
Volunteer Program Manager
858-452-3663 ext. 100
[email protected]
Waiver and Release of Liability
Name: ________________________________________ E-mail Address: _____________________________________
(First)
(Last)
Mailing Address: _____________________________________________________________________Apt # _________
City, State: __________________________________ Zip: _____________ Phone: _____________________________
Date of Birth: ______________ Group Name: ______________________ I want to receive monthly e –newsletter____
Emergency Contact
In case of emergency please contact: ______________________________________ Phone:_____________________
Policies and Procedures that I will follow:


















Close toed shoes are required to enter distribution center – tennis shoes or running shoes work great!
Wear proper work clothes (clothes you do not mind getting dirty). No jewelry.
Feeding America San Diego will not be responsible for any missing personal belongings, please leave in your car.
Bringing work gloves is recommended, but not required.
All volunteers must sign in and wear a name tag before volunteering begins.
Eating or drinking is permitted only in the break room.
Wash your hands before and after handling food items. Even when wearing gloves.
Running, horseplay, riding pallet jacks, and stepping on pallets is a safety hazard and not permitted.
Safety is first priority, please be mindful of the forklifts, using proper lifting techniques, and displaying mature behavior.
Food and other products may not be removed from the warehouse. No throwing or horseplay with food.
Use proper lifting techniques: when lifting heavy objects, use your legs to push upwards, keep your back straight and your
body balanced. Don’t attempt to lift over 50 lbs without assistance.
Report all accidents and injuries immediately to warehouse staff.
Sexual harassment, violence, or offensive speech will not be tolerated.
No one under the influence of drugs and/or alcohol will be permitted to volunteer.
Only trained staff are allowed to operate forklifts.
No cell phone usage or iPod/mp3 headphones in the distribution center.
Volunteers are responsible for cleaning up their area.
Please use the correct trash receptacles; recycling is very important to FASD!
Waiver and Release of Liability
In connection with my voluntary involvement in activities undertaken for, and / or with the participation and support of Feeding America San Diego, I, the undersigned, hereby
agree, for myself, my heirs, assigns, executors, and administers to release and discharge Feeding America San Diego and its nonprofit partner agencies, its officers and
directors, members, partners, funders, employees, agents, and volunteers Releasees) from all claims, demands, and actions from injuries sustained to my person and / or
property as a result of my involvement in such activities, whether or not resulting from negligence. I agree to release and hold Feeding America San Diego and its Releasees
harmless from any cause or action, claims or suit arising there from. I hereby attest that my attendance and involvement in such activities is voluntary, that I am participating at
my own risk and that I have read the foregoing terms and conditions of this release. I understand in the case of accident or injury that my health insurance is the primary
insurance coverage. I hereby confirm, represent and warrant that I have never been charged with or convicted of any crime involving or relating to child abuse or
neglect, child pornography, child abduction, or any other violent offense, including kidnapping, domestic violence, rape or any sexual offense, or who have ever
been ordered by a court to receive psychiatric or psychological treatment in connection therewith. I agree that I will perform activities that I am comfortable performing
and will follow all instructions. I also grant full permission for Feeding America San Diego and their Releasees, to forever use photographs, videos, audios or quotations from
me in legitimate accounts and promotion of Feeding America San Diego activities, with or without identification of me by name, and without compensation. This includes
Feeding America San Diego’s website, Facebook, Twitter, and other social media and media sources. In the course of volunteering at Feeding America San Diego, I
understand that I may work with confidential information. I agree to keep such information in the strictest confidence. I must abide by the volunteer policies and procedures
outlined above.
Print Name: _________________________________ Signature: _____________________________Date: ___________
Release of Liability for Minors: I, the undersigned parent or guardian of a minor participating with or without me, attests that I am over 18 years of age and warrant that I
have legal authority to execute the above agreement on my child or legal ward's behalf. I have read the foregoing Waiver and Release of Liability and I hereby give my
express consent to the irrevocable execution of this release on my child / legal ward's behalf.
Minor:
Print Name: _________________________________ Signature: _____________________ Date: __________
Guardian: Print Name: _________________________________ Signature: _____________________ Date: __________
COSMOS Preparation Checklist
Clothes: Clothing should be appropriate to the academic focus of the program and suitable for a learning environment. Many laboratories require long pants, long‐sleeved shirts, and close‐toed shoes. Bare midriff clothing is not allowed, other than designated swim times. San Diego is generally comfortable during the summer, but evenings can be cool. Appropriate Clothing :
Shirts, blouses, t‐shirts, sweatshirt, jacket
Jeans, slacks, pants, shorts (no “mini” shorts)
Dresses and skirts (appropriate for school)
Comfortable walking shoes (closed‐toe shoes
are required for labs)
Sandals & dress shoes (op onal)
Clothes for special occasions (dances &
Closing Ceremony) Swimsuit (appropriate for water sports/
ac vi es) Jacket, sweater, sweatshirt
AddiƟonal Items: Laundry soap, fabric so ener, dryer sheets
Money for laundry card
Hangers (NOT provided with housing!)
Flashlight & extra ba eries
Spending money for field trips & snacks
Personal Toiletries: Toothbrush & toothpaste
Dental floss & mouthwash
Disposable shaving razors/foam/gel (if needed)
Bath towels & beach towels (NOT provided)
Bath scrub or wash‐cloth
Soap and/or body‐wash
Facial cleanser
Shampoo & Condi oner
Hair brush, comb, and hair products
Deodorant
Sunscreen, sunglasses, chaps ck
Medica on (prescribed & store‐bought)
Shower shoes (flip flops, Tevas, etc)
OpƟonal Items : Extra pillows, blankets, comforters (1 small
pillow, 2 flat sheets, and 1 blanket will be provided to each student) Camera & charger
Alarm clock, desk lamp, freestanding mirror
Postage stamps, envelopes, sta onary
Cell phone & charger or pre‐paid phone card
Fan
Music device (e.g. iPod) & headphones
Non‐perishable snacks (e.g. granola bars,
fruit roll‐ups, nuts, refillable water bo le, etc) Laptop (please see page 12), Ethernet cable
Laptop Lock
PROHIBITED ITEMS: DO NOT bring to UCSD Cars, motorcycles, bikes, skateboards, etc Pets/animals of any kind Weapons, including knives, razor blades, etc Non‐prescribed drugs, alcohol, tobacco products Matches, lighters, candles, fireworks Hot plates, cooking appliances, refrigerators  Televisions Bicycles, skates, skateboards, scooters, etc Halogen lamps (due to fire hazard) DO NOT WEAR: Valuable jewelry or clothing Cut‐off or mini‐shorts or skirts
Jeans with holes Low/revealing/bare midriff tops Clothing with inappropriate language/artwork or colors associated with gangs High heels or pla orm shoes Oversized shirts or pants POSSESSION OF PROHIBITED ITEMS IS GROUNDS FOR IMMEDIATE DISMISSAL FROM THE PROGRAM WITHOUT REFUND School Supplies: (binder, note and lab paper provided) Backpack
Pens, pencils, highlighters, etc
Scien fic calculator
USB (2MB or more)
DO NOT BRING VALUABLES! THE UNIVERSITY WILL NOT BE RESPONSIBLE FOR LOST OR STOLEN PROPERTY