Student Application. Student Name Nick Name. Address. City State Zip Code. Address

Transcription

1 General Information (PLEASE PRINT CLEARLY) Residential Intensive Summer Education (RISE ) Program 2012 Student Application Cal Poly Pomona Office of Admission and Outreach, Building 98-4 th floor Attn: RISE 3801 W. Temple Ave. Pomona, Ca (909) /Fax (909) Student Name Nick Name Address City State Zip Code Birth / / Gender : Male Female Address Parent/ Legal Guardian Contact Name(s) Parent/ Legal Guardian Phone# ( ) - (Circle one) Home/ Work/ Cell Parent/ Legal Guardian Address: Emergency Contact #1( ) - (Circle one) Home/ Work/ Cell Emergency Contact# 2 ( ) - (Circle one) Home/ Work/ Cell Relationship to you How did you hear about the RISE Program? What is your T-shirt size? (Circle one) X-Small/Small/ Medium/Large/Other Academic Information and Interests Subject(s) of Interest Major/Minor (if applicable) **Cumulative GPA: Year of Graduation/ Year Graduated: I graduated from/ attend the following high school: ** High school students only: A copy of high school transcript will be requested if admitted in the program Hobbies/ Extra-Curricular Activities: 1

2 Parent/ Guardian signature Listed below is what you will need to bring: RISE Program Check List Six Changes of Clothing Your dress should be casual. If you wish to swim, please bring your bathing suit or swim trunks. All attire MUST BE TASTEFUL: blue jeans, shorts, T-shirts, tennis shoes, sandals etc. The rule of thumb is to be comfortable but not obscene. ALARM CLOCK We will be starting early each day, so if you have trouble waking up in the morning, BRING AN ALARM CLOCK!!! LAUNDRY DETERGENT If you need to wear certain garments over again, the university has a laundry facility. You need to bring your own detergent. (Please bring money for washing machines) PERSONAL TOILETRIES Please bring a bar of soap, a washcloth, towel, shampoo, toothbrush, toothpaste, deodorant, and other appropriate toiletries. MONEY All of the things you need to participate in the RISE Program workshops will be provided. There are other attractions at Cal Poly Pomona that might occupy your time. Therefore, you may want to bring extra money for your personal use. NO PET OF ANY KIND! RESTRICTED ITEMS (Note: Failure to follow any of the below listed restrictions may result in expulsion) No dogs, cats, hamsters, rats, lizards, frogs, turtles, snakes, or anything that breathes and is not human! NO COOKING APPLIANCES OF ANY KIND! No toasters, blender, hot plates, coffee pots, etc NO Appliances! NO FIREARMS, KNIVES OR EXPLOSIVE DEVICES OF ANY KIND! Absolutely no B.B. Pellet guns, slingshots, spray paint, paint ball guns, hand guns, firecrackers, or explosive devices of any kind! 2

3 NO ILLEGAL DRUGS! NO ALCOHOL! NO CIGARETTES! By signing below, the undersigned acknowledges that he/she student and parent/guardian has read and understood this R.I.S.E Checklist of What to bring and Restricted Items Signature of Parent/ Guardian Students signature Student s Printed Name Medical Consent/Release Form As the undersigned parent/ legal guardian of, I request that in my absence the above named minor child be admitted t any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, nurses, dentists, and staff to perform and diagnostic procedures, treatment procedures, and operative procedures to the above named individual. I have not been given any guarantee as to the results of any treatment if performed on the above named individual. I hereby accept ant financial responsibility for any and all medical treatment necessary to be administered to the above named minor child in the event of an accident, injury, sickness, etc. Any authorized representative of the R.I.S.E Program or Cal Poly Pomona is designated to act on my behalf until I have been contacted. Student Name Student Address Family Physician: Phone Number: ( ) - Name of Parent/ Guardian: Address: City/State/ Zip: Phone: (Home) ( ) - (Work) ( ) - (Cell) ( ) - 3

4 Person Responsible for charges (If different from above) Address: City/State/ Zip: Phone: (Home) ( ) - (Work) ( ) - (Cell) ( ) - Person to notify of parent/ guardian is not available: Phone: (Home) ( ) - (Work) ( ) - (Cell) ( ) - Insurance Carrier(s): Poicy Number: Signature of Parent / Guardian: : California State Polytechnic University, Pomona Medical Information To Be Completed by a Parent or Legal Guardian Child s Name Age Sex Height Weight List any serious and/ or operations your child has had: Known allergies, including any allergies to medicine: Check any of the following to which your child is susceptible: Bedwetting Asthma Upset Stomach Sinus Trouble Headaches Ear Trouble Fainting Spells Colds Hay Fever Heart trouble Sunburn Sleepwalking Sore Throats Skin Infection Hyperactivity 4

5 Check any of the following to which your child has had: Measles Diphtheria Scarlet Fever Mumps Heart Disease Smallpox Chickenpox Typhoid Whooping Cough Diabetes Is your child taking any medication? If yes, What? Immunization Information Tetanus shot this year? Polio Vaccine? Measles Vaccine? If yes, when? If yes, when? If yes, when? Signature of Parent or Legal Guardian 5

6 Parental Release for R.I.S.E Photos and Quotations (Including quotes from the student evaluation of R.I.S.E 2012 Program) I hereby grant Cal Poly Pomona, and the Office of admissions and Outreach, their legal representatives And assigns, those for whom they are acting, and those acting with their authority and permission, the absolute right and permission to copyright and use re-use and publish, republish display or otherwise use photographic portraits of my child or in which my child may be includes, in whole or in part, or composite or distorted in character or form, without restriction as to changes or alterations, from time to time, whether or not in conjunction with my child s own name, or reproductions thereof in color or otherwise made through any media at their studio or elsewhere for art, advertising, trade, or any other purpose whatsoever. This also extends to photographs of my child s R.I.S.E. summer 2012 design project. Without limiting and generality of foregoing, I hereby assign to Cal Poly Pomona and the Office of Admissions and Outreach any copyright ownership or any rights to obtain a copyright in any of the foregoing portraits or pictures. I also consent to the use of any printed matter in conjunction therewith, including quotations (with or without attributions) from the summer 2012 R.I.S.E Program discussions and/or program evaluation forms. I hereby waive any right that I may have to inspect or approve the finished product of products or the advertising copy or printed matter that may be used in connection therewith or the use to which it may be applied. I hereby release, discharge, and agree to save harmless Cal Poly Pomona and the Office of Admission and Outreach, their legal representatives or assigns, and all persons acting under their permission or authority of those for whom they are acting, from any liability by virtue of any use, re-use, publication, re-publication, blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produces in the taking of said picture or pictures or in any subsequent processing thereof, as well as any use, re-use, publication, or re-publication thereof. I hereby warrant that I am of full age and have every right to contract my child s name in the above regard. I state further that I have read the above authorization, release and agreement, prior to its execution, and that I am fully familiar with contents thereof. I acknowledge that I have been advise to consult anu attorney before executing this document, which contains legally binding promises. : Minor s Name (print): Parent s Name (print): Parent s Signature: Address: Witness Signature: 6

7 California State Polytechnic University, Pomona General Release The Undersigned recognizes and agrees that the State of California, the Trustees of the California State University, California State Polytechnic University, Pomona and their officers, agents and employees assume no responsibility for any liability, damage of injury that may be caused by the student s negligence of willful acts committed, related to, or during participation in R.I.S.E, or for any other participation in the program. The undersigned further agrees to hold harmless, defend, and indemnify the State of California, the Trustees of the California State University, California State Polytechnic University, Pomona and their officers, agents and employees from any and all claims, injuries, damages, losses, causes of action, and demands, and all costs and expenses incurred in connection therewith resulting from or in any manner arising out of or in connection with the student s intentional or negligent acts. Please Print Student s Name Student s Signature Parent or Legal Guardian Signature 7

8 California State Polytechnic University, Pomona Parent Sign- Off Sheet of RISE 2012 Program I have Read the student participation Checklist and understand what is expected of my child. I have read the authorization to consent to medical treatment form for my child and understand its contents. Signature of Parent or Legal Guardian Student s Printed Name 8