GirlsinEngineeringParentalPermissionFormSummer2015

DearParent/Guardian:

Congratulations!YourdaughterhasbeenacceptedintotheGirlsinEngineeringsummer
th
th
camp,forsession1:July13
July17
.PleasecompletethispacketandmailitbyMay
nd
22.Youcanalsoscanandemailtogirlsinengineering@gmail.com.

GirlsinEngineering
BaskinSchoolofEngineering:SOE3
UCSC1156HighStreet
SantaCruz,CA95064

orFAXitto8314595333

Thisprogramis
completelyfree
.Thereisnoapplicationfeeandthereisnofeetoattend.In
addition,freedailybustransportationwillbeprovidedfromseveralstopsintheSalinasand
WatsonvilleareatotheUCSCcampuswherethecampwilltakeplace.Ifyoucannotfind
transportationforyourchildtotheshuttlestopnearestyou,pleasecontactusrightaway.

YoucanlearnmoreabouttheGirlsinEngineeringprogramathttp://gie.soe.ucsc.edu/.

STUDENTINFORMATION
Name:_____________________________________________________________________
School:____________________________________________________________________
th
th
Grade(7
or8
):_____________________________________________________________
MailingAddress:_____________________________________________________________
City/State:______________________________________ZipCode:___________________
ParentPhone:_____________________AlternatePhone:____________________________
StudentPhone(ifstudenthasacellphone)________________________________________
Email:_________________________________________
Tshirtsize:____________________

TheabovenamedstudenthasmypermissiontoattendGirlsinEngineeringatUCSC.

Parentname(print):________________________________________________________

Parent/GuardianSignatureRequiredforParticipation:__________________________

STUDENTBEHAVIORAGREEMENT
UNIVERSITYOFCALIFORNIA,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.

Thefollowingwill
n ot
betolerated:
o

Denigrationofanotherpersononthebasisofrace,sex,sexualorientation,nationalorigin,ordisability

Useoffoulorinappropriatelanguage

Possessionand/orconsumptionofalcoholicbeveragesorillegaldrugs

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

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.

Smokingoruseofanyformoftobacco

Tamperingwithanycomputertechnology,websites,orfire&safetyequipment

Theftorpropertydamage

StudentswhoabuseordamageUniversitypropertywillbebilledforcostsordamage.

Studentsmustabidebythefollowingdresscode:
o

Acceptable clothing includes: walking shorts, jeans & pants, tshirt, blouse orknitshirt,comfortableshoes(tennis
shoes,etc.),sandals,skirts,

Unacceptable clothing includes: undergarments worn as clothing, clothing with profanity or advertisements for
alcohol or tobacco products,lowcut,backless,strapless,oroverlyrevealing clothing.
S unglassesand hatsmustbe
removedinclassorwhenrequested.

Studentsmaynotbringcellphones,CDplayers,iPods,and/orMP3playerstoclassorotheracademicactivities.

Although we will makereasonableeffortsto ensurethesafety ofpersonalproperty,GIEisnotresponsiblefordamageand/or

lossofanypersonalproperty.

StudentsareexpectedtobeconsideratetoallGIEstaffandpeers.

IunderstandthatifI,__________________________________(PrintParticipantsName)failtoabidebythe
rulesofconductcitedabove,appropriateconsequenceswillbeenforced.Thiscouldinclude(butisnotlimitedto)
adiscussionwithGiEstaff,orremovalfromtheprogram.Aparentorguardianwillbeconsultedwhennecessary.

__________________________________________
ParticipantSignature

__________________________________________
SignatureofParent/GuardianofMinor

Date


ELECTIVE/VOLUNTARYACTIVITYWAIVER
UNIVERSITYOFCALIFORNIA,SANTACRUZ
GirlsinEngineering(GiE)

WaiverofLiability,AssumptionofRisk,andIndemnityAgreement

PrintNameofGiEParticipant
ParticipantsDateofBirth

Waiver: In consideration ofbeing permitted to participatein any way in

GirlsinEngineering (GiE)
,I,formyself,
my heirs, personal representatives or assigns,
do hereby release, waive, discharge, and covenantnotto sue
The
Regents of the University of California, its officers, employees, and agents from liability
fromany andallclaims
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 lossarising from,butnotlimited
to,participationinGIE.

SignatureofParent/GuardianofMinor
Date
SignatureofParticipant
Date

Assumption of Risks:
Participation in
GiE carries with it certain inherent risks that cannot be eliminated
regardless of the care taken to avoid injuries. The specificrisksvaryfromoneactivitytoanother,buttherisks
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,andconcussionsto3)catastrophicinjuriesincludingparalysis
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 assumeall
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,
damagesandliabilities,includingattorneysfeesbroughtasaresultofmyinvolvementin
GiEandtoreimburse
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 permittedbythelawoftheStateofCaliforniaandthat
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, includingmy
right to sue
. I acknowledge that I am signing the agreement freely and voluntarily, and
intend by my
signaturetobeacompleteandunconditionalreleaseofallliability
tothegreatestextentallowedbylaw.

SignatureofParent/GuardianofMinor
Date

Date

SignatureofParticipant

PHOTOGRAPYANDEVALUATIONWAIVER
UNIVERSITYOFCALIFORNIA,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 astudytodeterminetheeffectiveness

ofGiEwhichincludesthefollowing:

I give permissiontoallowmydaughtertofilloutsurveys,andparticipateininterviewsto

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,andtestscoresthroughtwelfthgrade)whichwillbemaintainedinelectronicfiles.
Thisinformationwillbemaintainedwithstrictconfidentiality.

I understand that some of theinformationmayresultinpublication,butthatallresponses

willbetreatedasconfidentialandwillbereportedasagroup.Detailsaboutindividualsor
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 suchuse. PleasenotethatindicatingNowillalsoresultintheremoval
ofyourdaughterspicturefromGiEpublicationsintendedforthegirlstokeep.

__________________________________________________
PrintNameofGiEparticipant

__________________________________________________
PrintNameofParent/GuardianofMinor

__________________________________________________
SignatureofParent/GuardianofMinor
Date

MEDICALRELEASEINFORMATION
UNIVERSITYOFCALIFORNIA,SANTACRUZ
GirlsinEngineering(GiE)

Pleaseprovidetheinformationoftwoindividuals(suchasafriendorrelative)thatcanactasanemergencycontactforyour
childifyoucannotbereached.

Name:

_
PhoneNumber:(
)

Address:

_
City:
ZipCode:

Relationshiptostudent:

Name:

_
PhoneNumber( )

Address:

_
City:
ZipCode:

Relationshiptostudent:

Isyourchildcoveredbyamedicalplan? Yes
No

Ifyes,nameofplan/insurance:
_
PlanID#:

DoctorsName:
Phone:

Isyourchildonanymedication? Yes
No

Ifyes,listthenamesofthemedication:

Doesyourchildhaveanyallergiesoralifethreateningconditionweshouldbeawareof? Yes
No

Ifyes,providedetails:

Yes No

Iauthorizemychildtobegivennonprescriptionmedicinesuponherrequest(example:Alka
Seltzer,PeptoBismol,Ibuprofen,etc.)

PermissionforEmergencyTreatment
I 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,

, toparticipateintheGirlsin
EngineeringprogramandIherebyacknowledgethatatthepresenttime,mychildisingoodphysicalhealth.

__________________________________________________________________________________________

PrintNameofParent/GuardianofMinor
SignatureofParent/GuardianofMinor
Date

TRANSPORTATIONCONSENTFORM
UNIVERSITYOFCALIFORNIA,SANTACRUZ
GirlsinEngineering(GiE)
GiEhascontractedUCSCTransportationServicestoprovidetransportationtoandfromtheprogramvenuefor
thedurationoftheprogram.Thebusstopsandtimesaresubjecttochangebasedondemandfromthestudents.

No
,mychildwillnotusethetransportation

Yes
,mychildwillusethetransportationprovided.(Pleasecirclethelocationbelowwhereyourchildwillbe
pickedupanddroppedoff.)

MorningRoute
Stop1

AfternoonRoute

ChualarSchool
24285LincolnStreet,Chualar,CA
Leaves7:15am

SalinasElSausalMiddleSchool
1155EastAlisalStreet,Salinas,CA
InfrontofschoolintheGreenParkingZone
Leaves7:35am

Leave

UCSCJackBaskinEngineeringBuilding
Classendsat3:00pm

Stop1

CapitolaNewBrightonMiddleSchool
250WashburnAve.,Capitola,CA95010
Leaves3:30pm

Stop3

CastrovilleCommunityCenter
CornerofPomberSt.andPrestonSt.
Leaves8:00am

Stop2

Stop4

WatsonvilleCesarChavezMiddleSchool
(Busstopsinfrontofthegym)
440ArthurRd
Watsonville,CA95076
Leaves8:20am

CapitolaNewBrightonMiddleSchool
250WashburnAve.,Capitola,CA95010
Leaves8:40am

UCSCJackBaskinEngineeringBuilding
Classstartsat9:00am

Stop3

WatsonvilleCesarChavezMiddleSchool
(Busstopsinfrontofthegym)
440ArthurRd
Watsonville,CA95076
Leaves3:45pm

CastrovilleCommunityCenter
CornerofPomberSt.andPrestonSt.
Leaves4:00pm

Stop4

Stop5

Stop2

Stop5

Arrive

SalinasElSausalMiddleSchool
1155EastAlisalStreet,Salinas,CA
InfrontofschoolintheGreenParkingZone
Leaves4:20pm

ChualarSchool
24285LincolnStreet,Chualar,CA
Leaves4:40pm

Iherebygrantpermissionformychild,torideontheshuttlecontractedbyGirlsinEngineeringprogramforthe
durationoftheprogram.Ifyoucannotfindtransportationforyourchildtotheshuttlestopnearestyou,please
contactus.
__________________________________________________
PrintNameofParent/Guardian

__________________________________________________
SignatureofParent/Guardian
Date