HIGHER

OPPORTUNITY
PROGRAM FOR
EDUCATION
220 Westwood Plaza
Student Activities Center 106D
Los Angeles, CA 90095
office: 310.267.4346
fax: 310.206.3175
jthach@cpo.ucla.edu

Spring Field Trip:
2014 RISE Retreat
Date: Friday, J une 20, 2014 to Sunday, J une 22, 2014
Time: Friday, 5:30 AM Sunday, 9:00 PM

The Higher Opportunity Program for Education (HOPE) at UCLA invites you to our 2014 RISE Retreat! This
event will take place from Friday, J une 20, 2014 at 5:30AM to Sunday, J une 22, 2014 - 9:00PM in Northern
California Oakland and Berkeley!
HOPEs RISE component (Reaching Independence through Self Expression) is a space for students to learn about
their options after graduating from high school and to develop applicable skills for the transition into adulthood.
They will be supported through the college application process and exposed to diverse institutions of higher
education such as community colleges, California State Universities (CSU), Universities of California (UC),
private institutions, and alternative institutions of higher education. The annual RISE Retreat seeks to help juniors
and college-bound seniors transition into the next academic year.
Through this retreat, we hope students will have a better idea of what choices to make in the future! If you haven't
heard of us before, the Higher Opportunity Program for Education [HOPE] is a student-initiated project from
UCLA that seeks to provide access to academic, community, and personal resources for high school students. We
tutor, peer-advise, and provide leadership opportunities, workshops and the extra guidance to disadvantaged
students out there in our community. If you would like more information about us, please contact us at
jthach@cpo.ucla.edu or call our office, (310) 267-4346.
Space is limited, so we ask that students check their availabilities as soon as possible. Deadline to sign up and turn
in the permission slips is Sunday, June 8th

by 11:59PM. If you need an extension, please contact the Project
Director as soon as possible.
Please be ready to be picked up at the following times:
San Gabriel High School 5:30AM at the SGHS Horseshoe Turnaround
Westminster High School 5:30AM at Popeye's (Westminster & Goldenwest)

Students are expected to be back by 9:00PM at the latest on Sunday.

We are going to be eating in Northern California throughout the weekend, so bring enough money for at least 3
meals (plus emergencies)!

If there are any questions, feel free to contact:
Project Director, J essica Thach @ 510-387-1874 or jthach@cpo.ucla.edu
OR
Academic Development Coordinator, Daniel Dang @ 714-337-5921 or danndang@gmail.com


HOPE is a student organization registered with the UCLA Center for Student Programming. The University bears no responsibility of any kind for the functions, roles, and
actions of HOPE and its events, nor those involved in any way. Vol 11/08




HIGHER
OPPORTUNITY
PROGRAM FOR
EDUCATION
220 Westwood Plaza
Student Activities Center 106D
Los Angeles, CA 90095
office: 310.267.4346
fax: 310.206.3175
jthach @cpo.ucla.edu

Participants Name:

Participants E-mail:

Higher Opportunity Program for Education at UCLA

Waiverof Liability, Assumption of Risk, and Indemnity of Agreement

Waiver: In consideration of being permitted to participate in
2014 RISE Retreat from Friday, June 20, 2014 @ 5:30AM to Sunday, June 22, 2014 @
9:00PM


Thereinafter called RISE Retreat, I, for myself, my heirs, personal representatives or assigns, do hereby release,
waive, discharge, and covenant not to sue Higher Opportunity Program for Education (HOPE) and its agents from
liability from any and all claims including the negligence of Higher Opportunity Program for Education (HOPE) and
its agents, resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not
limited to, participation (including transportation, if applicable) in RISE Retreat.


Signature of Parent/Guardian, if Minor Date Signature of Participant Date

Assumption of Risks: Participation in RISE Retreat carries with it certain risks that cannot be eliminated regardless of the
care taken to avoid injuries. Specific risks may vary, but the risks range from 1) minor injuries such as scratches, bruises,
and sprains to 2) major injuries such associated with slips and falls, and concussions to 3) catastrophic incidents including
paralysis and death.

I have read the previous paragraph and I know, understand, and appreciate these and other risks that are
possible from my participation in RISE Retreat. I hereby assert that my participation is voluntary and that I
knowingly assume all such risks.

Indemnification and Hold Harmless: I also agree to indemnify and hold Higher Opportunity Program for Education
(HOPE), The Vietnamese Student Union at UCLA, 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 RISE Retreat and to
reimburse them for any 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 all liability to the greatest extent allowed by the law.

________________________________ _________ ____________________________________ ___________
Signature of Parent/Guardian, if Minor Date Signature of Participant Date

Participants Age


HOPE is a student organization registered with the UCLA Center for Student Programming. The University bears no responsibilit y of any kind for the functions, roles, and
actions of HOPE and its events, nor those involved in any way. Vol 11/08

HOPE IS A STUDENT ORGANIZATION REGISTERED WITH THE UCLA CENTER FOR STUDENT PROGRAMMING. THE UNIVERSITY BEARS NO RESPONSIBILIT Y OF
ANY KIND FOR THE FUNCTIONS, ROLES, AND ACTIONS OF HOPE AND ITS EVENTS, NOR THOSE INVOLVED IN ANY WAY.

HIGHER OPPORTUNITY PROGRAM FOR EDUCATION (HOPE)
RISE Retreat 2014: JUNE 20-22, 2014
Application Due: Sunday, June 8
th
, 2014 @ 11:59 PM
Please complete all information as
neatly as possible. All
information will be kept
confidential.
STUDENT INFORMATION
Student Name:
Date of Birth: Male Female
Current street address:
City: ZIP Code: Home phone:
Student Cell phone: School: Grade:
Email address:
PARENT CONTACT AND MEDICAL INFORMATION
* ALL STUDENTS MUST HAVE MEDICAL INSURANCE TO PARTICIPATE IN HOPE SPONSORED
ACTIVITIES *
Name of Mother/Guardian: Name of Father/Guardian:
Mother/Guardian Cell Phone: Father/Guardian Cell Phone:
Mother/Guardian Work Phone: Father/Guardian Work Phone:
Mother/Guardian E-mail: Father/Guardian E-mail:
Health Insurance Company: Insurance ID #:
Family Doctor/PCP: Physician Phone:
Student allergies:
Student medication(s):
Last immunization (Year): Last booster shot (Year): Last tetanus shot (Year):
Does the student have any physical limitation or medical condition that we should be concerned about?
PARENT(S), PLEASE ATTACH A COPY OF
YOUR CHI LDS HEALTH I NSURANCE CARD
I certify that the above information is accurate to the best of my knowledge. I do hereby give consent to UCLA-HOPE and its
employees and agency to render or seek emergency medical treatment and assistance to the participant if deemed
necessary. I also acknowledge that unless in case of extreme emergency exists, no medical treatment will be sought for my
child without my prior approval or that of the alternate party listed above. In consideration of granting for permission by
UCLA Higher Opportunity Program for Education for the above named minor to participate in the activities sponsored by
HOPE, the participant, his/her parents or legally appointed guardian hereby agree to indemnify, hold harmless, release and
forever discharge the UCLA Higher Opportunity Program for Education employees and/or agents from all claims and
demands which the participant, his/her parents or legal guardian or the representatives or successors of them or any person
may have against UCLA and its employees and agents by reason of acts, illness or injury, or other consequences arising or
resulting directly or indirectly from the participation of said minor in the aforementioned HOPE activities. Any unrevealed
medical/physical condition that arises during the trip can be cause for students dismissal. HOPE will not be responsible for
controlling or distributing any type of medication. I release my photo and work to be used by HOPE for publication.
Signature of student: Date:
Signature of parent: Date: