1 COSMOS 2017

Dear COSMOS Student,

WELCOME LETTER

Congratulations and welcome to COSMOS at UC Santa Cruz!

You’ve demonstrated an extraordinary interest and aptitude in math and science and now all of your hard work is

about to pay off! You are joining an elite group of scholars who have earned the opportunity to participate in a

truly unique program. Not only do you get to experience university life from the inside, but you also get to do it

on one of the most beautiful campuses in the United States!

At COSMOS, you will have:

A hands-on, exciting and intense exploration of your interests in math and science.

Interaction with university faculty who are currently working at the forefront of science and technology.

A once in a lifetime opportunity to hear from world famous scientists and mathematicians.

Visits to laboratories and research facilities where the important questions of today are being answered.

The opportunity to ride a roller coaster at the Santa Cruz Boardwalk, kayak with otters on the Monterey

Bay, and much more.

A community of students like you who have the unquenchable need to learn.

Many teachers, researchers and mentors working together to prepare, excite and motivate you to continue on

the path towards success.

Come prepared to learn and to be challenged, but most of all get ready to have the time of your life! COSMOS

has profoundly affected the lives of many students and now it’s your turn!

Again, congratulations on your acceptance – we look forward to meeting you!

Raul Ebio COSMOS Program Director

University of California Santa Cruz

Sincerely,

2 COSMOS 2017

COSMOS Form Return Checklist

Please return all of the following forms to the COSMOS office by June 1st. You may want to make a copy of each form for your records.

Parent Guidelines

COSMOS Student Agreement

Elective/Voluntary Activity Waiver

Internet Usage Agreement form

Media Release Form

Off-Site Parental Permission form

Health Facility Information Form

Confidential Health History Form

Copy of Front & Back of Insurance Card

Copy of Immunization Record

Be Sure to Read All Forms in Acceptance Packet

Please return this packet along with a check or money order for the full tuition amount made out to “U.C. Regents” to the address below. Credit card payments can be made through the COSMOS application website.*If you received full financial aid, you do not need to send any tuition. If you received partial aid, please send in a check for the remaining balance or pay the remaining balance online.

I have reviewed and read all the forms in this packet, and the student handbook website (cosmos.ucsc.edu/accepted) with my child.

Parent/Guardian Printed name

Parent/Guardian Signature Date

For regular U.S. postal mail

Attention: COSMOS

Educational Partnership Center

1156 High Street

Santa Cruz, CA 95064

For FedEx and/or UPS

Attention: COSMOS

Educational Partnership Center

Oakes College

233 Oakes Road Santa

Cruz, CA 95064

3 COSMOS 2017

COSMOS CONTACTS

We do our best to be available to families whenever possible. Please feel free to contact us via phone or

email at any time.

During the program, we will be located at:

Participant Name

COSMOS

Central Conference Office

1156 High Street

Santa Cruz, CA 95064

Office Phone: (831) 459-1766

Email: cosmos@ucsc.edu

Web site: http://cosmos.ucsc.edu

COSMOS Office Hours:

Monday – Friday 8:00 am – 5:00 pm

5:00 pm – 10:00 pm voicemail is checked and returned

10:00 pm – 8:00 am voicemail will be returned in the morning

COSMOS staff can be reached at the following:

Raul Ebio

UCSC COSMOS Director

(831) 212-1568

raule@ucsc.edu

KeShawn Williams

UCSC COSMOS Residential Program Manager

(831) 459-1766

kenowill@ucsc.edu

Jose Cordova

UCSC COSMOS Interim Academic Support Coordinator

(831) 459-1763

jodcordo@ucsc.edu

Brett Bell

UCSC COSMOS Coordinator for Residential Education (CRE)

(831) 247- 7631

4 COSMOS 2017

PREPARING FOR THE PROGRAM

WHAT TO BRING

Essential:

Clothing for both hot and cold weather. Note: Summertime fog in Santa Cruz means mornings

and evenings are quite chilly.

Closed-toe walking shoes. Note: The UCSC campus is large and has many steep hills.

Students will need to have comfortable shoes suitable for walking moderate distances.

Toothbrush, toothpaste, soap, shampoo, hairbrush, etc.

Sunscreen & hat for sun protection

Sheets & blankets or sleeping bag for an extra-long twin (it gets cold at night!)

Pillow & pillow case

Towels for shower and pool/beach

Laundry

https://www.revaluemycard.com/washlaundry/

If you choose to add money to your laundry card online, you will have to set up an account.

You can do so by clicking here Registration

Pens/pencils, paper and school supplies.

Medication Note: All medication must be listed on Health history/services form. COSMOS

staff cannot administer any medications so students should bring anything they may need.

Optional

Personal Computer and Ethernet Cable (Highly recommended, but not required. You will have

access to our computer lab during study hall hours. Wireless is available all over campus, however

wireless access can be spotty or weak in certain areas of the dorms.)

Alarm clock

Coat hangers

Backpack

Swimsuit

Shower shoes/flip flops

5 COSMOS 2017

Pre-paid calling card (These are also for sale on campus)

Cell phone

Camera

Radio or MP3 player

Movies (No R-rated movies), games, or sports equipment (some will be provided)

Calculator (some will be available for student use)

Spending money. Note: Students will need spending money for laundry or if they would like to buy

something at the UCSC bookstore or Santa Cruz Beach Boardwalk.

Snack food. Note: Three meals will be provided every day, including when students are away from

campus on field trips, but the dining hall will be closed when not serving breakfast, lunch, and

dinner.

Please Do Not Bring

An automobile and/or bicycle

Valuable items

Weapons, fireworks, explosives, candles

Drugs, alcohol, or e/cigarettes

Skateboards or rollerblades (Not permitted on campus)

Pets (this includes opening and closing day; dogs are not permitted on the UCSC campus)

HOUSING AND DINING

Keys & Keycards

Upon arrival, each student will receive a key to their room and a keycard providing access to their residence

hall. Students should lock their door at all times and keep their key with them. It is against policy to give a room

key to anyone else besides authorized COSMOS staff. The fee for a lost or damaged key or keycard is $75.00,

which you will be responsible for replacing.

Wristband

A wristband will be given to each student and will be required for access into the Dining Hall. The fee for a lost

or damaged wristband is $35.00, which again, you will be responsible for replacing.

6 COSMOS 2017

CONTACTING STUDENTS

Mail If family and friends will be sending mail, send it early in order for it to be received during the beginning of the

program. All mail for COSMOS students should be addressed as follows:

Participant’s Name

C/O COSMOS

Central Conference Office

1156 High Street

Santa Cruz, CA 95064

Please note that due to office location logistics, there may be up to a one day delay between mail deliveries to

the COSMOS office and when the student participant receives the letter or package.

Please do not mail perishable food items to your student.

Phone Telephone lines are no longer active in our dorm rooms. Cell phones are only permitted outside of class.

The best times for you to contact your student or for your student to call you:

● Weekdays: During rec time/dinner (3:30pm-6:30pm) and study hall/bed time (8:30pm-10:30pm)

● Weekends: Varies. It depends on the activities planned for those days.

A message can be left for COSMOS students by calling the COSMOS Office at (831) 459-1766. A staff

member will be in this office Monday through Friday from 8:00 am – 5:00 pm. The office voicemail is checked

hourly between 5:00 pm – 10:00 pm and throughout the weekend.

In case of an emergency, contact a UCSC COSMOS staff member. See pg. 3

All students will have access to the internet. Students who bring a computer will have access to the internet

from their rooms.

7 COSMOS 2017

OPENING AND CLOSING DAYS

Opening Day: Sunday, July 9, 2017

1:00 pm – 3:00 pm: Student Check-In

Students will be assigned to one of the groups below for a designated move in time. During the registration,

students will receive keys, a meal wristband, information and move into their rooms.

Group A – Register between 1:00 and 1:40 p.m.

Group B – Register between 1:40 and 2:20 p.m.

Group C – Register between 2:20 and 3:00 p.m.

There will be minimal snack food available between 1pm and 3pm.

For those families arriving in Group A or Group B, once your student has moved in and settled, you’re welcome

to explore the campus, but be sure to return to the Registration area before 3pm.

3:10 - 5:00 pm: COSMOS Welcome and Individual Faculty Introductions

UCSC staff and faculty will welcome students and families and introduce them to their cluster group.

5:00 pm: Parent Departures

Parents depart and students begin COSMOS life.

Closing Day: Saturday, August 5, 2017

9:15 am: Families meet with students at the Engineering Courtyard.

9:15 am – 10:45 am: STEM Symposium

All families are welcome to view their student’s work and meet the COSMOS staff and faculty.

10:45 am: All walk to the COSMOS Closing Ceremony. This is a lengthy walk. Please bring comfortable

shoes.

11:00 am – 12:00 pm: COSMOS Closing Ceremony

12:00 pm – 1:00 pm: Check Out, say goodbyes. Enjoy the rest of your summer!

Parking is available west of College Nine. Be careful to avoid parking in spaces designated for campus staff or

requiring special permits. UCSC Parking Services will ticket anyone who parks illegally. Please do not bring

pets on Opening or Closing Days. In particular, dogs are not permitted on campus.

8 COSMOS 2017

Dear Parents,

PARENT GUIDELINES

We would like to congratulate you and your child on being accepted to the COSMOS 2017 Summer Program!

This is a wonderful opportunity for your child to strengthen their educational goals and also learn valuable life

skills.

Attending a residential summer camp is a challenging endeavor for most children whether or not COSMOS is

the first time your child will be away from home. Rest assured, the COSMOS program has prepared year round

to ensure that your child will have a safe and fulfilling experience.

As a loving and caring parent, you may also find it difficult to adjust to having your child be away from home.

We understand.

Below are Frequently Asked Questions (FAQ) that may answer the bulk of your questions. The Student

Handbook Website is available and has detailed information about the supervision and safety we practice to

keep your child safe.

Please take the time to review these documents and resources so both you and your child will be prepared to

make COSMOS a rewarding and worthwhile experience. It is also important to know that your child must

attend the entire program to fully benefit from and enjoy the experience. Leaving before the Closing

Ceremonies will impact your child’s learning and wonderful time at COSMOS.

If you have any other questions, please feel free to contact our office.

Sincerely,

I have read and understood the Parent Guidelines as well as the FAQ and will do my best to follow these guidelines.

Parent/Guardian Signature Date

9 COSMOS 2017

FREQUENTLY ASKED QUESTIONS

How much supervision is provided for my son/daughter? While students are ultimately responsible for their own conduct, administrative, instructional, and residential

staff all work together to provide supervision. Students are primarily supervised by the residential staff who live

in the residence hall with the students. The residential staff consists of a Coordinator of Residential Education

(CRE), two Senior Residential Assistants (SRA's) who oversee a staff of 16 UC Santa Cruz undergraduate

Residential Assistants (RA’s). All have cleared background and DMV checks and participate in an intensive

week-long training (including first-aid and CPR certification) prior to the program. The RA's ensure that

COSMOS rules and procedures are followed and that problems are handled immediately. They are

knowledgeable about the campus and college life and are available at all times to help students adjust to the

program and life away from home. During the day, from the dorms to the class rooms, students are escorted by

a COSMOS Teacher Fellow who is a high school teacher who works with the COSMOS faculty. In the

afternoon and evening, the Resident Assistants supervise the students until lights out.

Will my child be safe? The COSMOS policies are put in place to keep the students safe at all times. Some of these policies include:

Students must be in the dorms by 10PM and are not allowed to travel away from the dorm area alone. Students

must use the buddy system. See the COSMOS Handbook for more specifics on COSMOS policies. Parents will

know best if a student is capable of following the policies while away from home. If at any time, a student does

not feel safe, they should let a COSMOS staff member know so that the situation can be remedied.

COSMOS seems really strict. Can I authorize my child to have more freedom? Inevitably, there will be students who are given more freedom at home and feel that the rules at COSMOS are

too strict. There will also be students who have stricter rules at home and are surprised by the amount of

autonomy they are given. The COSMOS policies have been designed to help ensure each student's safety and

manage a large group of teenagers on the campus. There is one set of rules for all students, regardless of their

age or "freedom" allowed at home. Older students, or students who are used to operating more independently,

should consider this before coming to COSMOS.

What is the best way to communicate with my child? Students are kept very busy at COSMOS and often don't have a lot of time to devote to writing letters, email, or

calling on the phone. Even if you don't hear from them, trust that they love to hear from you. If you haven’t

heard from your child for an extended period of time please email or call one of the COSMOS staff who will

ge t a note to your child to contact you!

What should I do if my child is homesick? Four weeks can be a long time to be away from home (for the student and the parents). Before coming to

COSMOS, this should be discussed with your child. The first week is often the most difficult to get through.

Our staff will work hard to make sure that students are connecting with one another and feeling like they

belong. If you are concerned about your child's homesickness, please contact the COSMOS office immediately.

Our staff will work hard to help the student adjust to life at COSMOS. Nearly all students who initially

experience homesickness ultimately enjoy their COSMOS experience.

10 COSMOS 2017

While it can be extremely difficult, please do not respond to your child's "rescue call" by coming to campus to

talk them into staying. Once a student sees a ride home, there is rarely any turning back. If a student is begging

to come home, please call a COSMOS staff member so that we can discuss different options. While it may be

best for the student to go home in the end, we prefer to try other strategies first. Please be reminded that leaving

for any reason during COSMOS will not result in any amount of tuition refund.

Can I come visit and/or can my child come home on weekends?

As many families live too far to visit during the program, it is certainly not necessary to visit your child during

the four weeks. Weekend time allows students to establish friendships and become fully involved in residential

life. Non-academic outings are planned every weekend which most students don't like to miss. If you would like

to visit your child or bring him/her home for the weekend, you are required to email us at least 24 hours in

advance. No visitors, including parents, will be granted entrance into the residence hall once the program

begins.

Will I be able to send perishable items to my child via mail?

We strongly recommend that you do not send perishable items via the mail to your child. We notify the students

when they receive any mail, but because of their busy schedules, the students may not pick up the packages right

away. However, we welcome you to send your child letters and other packages that are non-perishable in the

mail.

May I attend lectures with my child?

Classroom time is the most engaging and important part of the educational aspects of COSMOS. We sincerely

ask that you do not take that valuable time away from your child by picking them up on weekdays or distracting

them with your presence while they are in their specific classrooms/attending Discovery Lectures. Regular class

lectures are not open to the public but the Discovery Lectures are open to the public, however, if you choose to

attend Discovery Lectures you will be asked not to sit with any of the COSMOS students, including your child.

Are weekend activities/field trips necessary?

Please allow your child to experience and participate in all of the activities our program provides them. This

includes the weekend activities. These experiences may have a pronounced impact on your child’s social

interactions and ability to be independent. Taking part in these activities may also influence your child’s ability

to be an avid participator and noticeably boost their confidence.

11 COSMOS 2017

COSMOS Student Agreement

● Students are expected to attend all classes, seminars, lectures, labs, and academic field trips each day on

time. Students are expected to participate in class activities and complete all assigned coursework. Special

circumstances, such as illness, must be reported to a staff member immediately.

● Students MUST arrive to COSMOS on Opening Day, July 9, 2017, and stay for the entirety of the

program (excluding weekend check-out that adheres to the COSMOS policy). Students MUST be picked up

by a parent or approved adult on Closing Day, August 5, 2017. There will be no exceptions to this rule.

● COSMOS students may leave the UCSC campus only when they are accompanied by COSMOS staff or

faculty, parent/guardian, or other pre-approved adult visitor. When students leave campus with a

parent/guardian or other pre-approved adult visitor, they must check-out through the COSMOS main

office. The student must leave his/her meal card and dorm/room keys with the COSMOS Office Staff.

These items will be returned to the student when they check back in with the COSMOS Office Staff.

● Students may only have visitors that are pre-approved by parent/guardian during weekend check-out

hours.

● Students must be on their assigned floor by 10:00 p.m. and be in their assigned rooms by 10:30 p.m. each

week night.

● Students are expected to be considerate of other students, staff and others living nearby on the UCSC

campus by controlling their noise level at all times. If a student is asked to lower the volume or reduce the

amount of noise, the expectation is for the student in question to accommodate the request and reduce the

amount of noise accordingly.

● Students are expected to be considerate and respectful to all COSMOS faculty, staff, and peers.

● The following will not be tolerated:

o Belittling of another person on the basis of race, religion, sex, sexual orientation, national origin,

or disability.

o Use of foul or inappropriate language.

o Possession and/or consumption of alcoholic beverages or illegal drugs.

o Possession of any type of weapon including knives, guns, pellet guns, B-B guns, sling shots,

water pistols, or any other kind of device that could inflict injuries to yourself or others.

o Violence, harassment, or abuse of any kind. This includes water fights, fist-fights, verbal abuse,

or any form of conduct that may cause another individual harm, potential harm, or needless

feelings of discomfort or embarrassment.

o Smoking or use of any form of tobacco, e-cigarettes or other substances. All UC campuses are

smoke and tobacco free as of January 1, 2014. (http://tobaccofree.ucsc.edu/)

o Tampering with any computer technology, web sites, or fire & safety equipment.

o Theft or property damage.

o Inappropriate conduct on the internet, including illegal downloads.

o Pranks of any kind will not be tolerated and may be grounds for immediate expulsion.

o Non-COSMOS participants may not visit COSMOS participants in their dorms or stay overnight.

12 COSMOS 2017

No exceptions. Having non-COSMOS guests in dorms is grounds for expulsion.

Students are not permitted to visit the dorm area occupied by students of the opposite sex.

COSMOS staff may enter a student’s room for any reason at any time. Appropriate concern for the

privacy of the occupants will be respected when possible.

Students who abuse or damage University property will be billed for the costs of damages, and will be

expelled from the program, with no refunds.

● No inappropriate physical contact is permitted. Couples are discouraged, as the program encourages

inclusivity, not exclusivity.

● Personal appearance & hygiene should be a matter of concern for each student. Students are expected to

be suitably dressed & well-groomed when representing COSMOS. Students must abide by the following

dress code:

o Acceptable clothing includes: walking shorts, jeans & pants, t-shirt, blouse or knit shirt,

comfortable shoes (tennis shoes, etc.), sandals, skirts, attire for dances and presentation

day/closing ceremony.

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

advertisements for alcohol or tobacco products, and low-cut, backless, strapless, or overly-

revealing clothing. Sunglasses and hats must be removed in class or when requested.

o On all field trips all students must wear a COSMOS t-shirt.

● Cell phones and MP3 players are permitted for use only during recreational time. Students may not use

these items in class or other academic activities.

● NO CARS ARE ALLOWED.

● NO PETS ARE ALLOWED.

● Although we will make reasonable efforts to ensure the safety of personal property, COSMOS is not

responsible for damage to or loss of any personal property.

If students fail to abide by the rules of conduct cited above, appropriate consequences will be enforced. This

could include (but is not limited to) a discussion with COSMOS staff or faculty, loss of recreation or field trip

privileges, or removal from the program. A parent or guardian will be contacted when necessary.

----------------------------------------------------------------------------------------------------------------------

By signing this agreement I, , and my parent/legal guardian,

, certify that we have read, understand, and agree with the

terms and conditions of the COSMOS Student Agreement, all Acceptance Packet sections, and any

additional COSMOS materials referenced. It is understood that by accepting the offer to attend the

COSMOS program and agreeing to abide by all COSMOS rules and regulations set forth, I am making a

commitment to complete the entire four weeks of the program.

Participant Signature

Parent/Guardian Signature

13 COSMOS 2017

Participant’s name: Please Print

ELECTIVE/VOLUNTARY ACTIVITY WAIVER

UNIVERSITY OF CALIFORNIA, SANTA CRUZ

California State Summer School for Mathematics and Science (COSMOS)

Waiver of Liability, Assumption of Risk, and Indemnity Agreement

Waiver: In consideration of being permitted to participate in any way in COSMOS, 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, participation in COSMOS.

Signature of Parent of Minor Date Signature of Participant Date Participant’s DOB

Assumption of Risks: Participation in COSMOS 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 and death.

I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in COSMOS. 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 The Regents of the University of California HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees brought as a result of my involvement in COSMOS 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 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 force and effect.

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 signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.

Signature of Parent of Minor Date Signature of Participant Date Participant’s Age (if minor):

14 COSMOS 2017

Internet Usage Agreement Form

COSMOS students are authorized to use internet and online services provided by the University of California Santa Cruz or in accordance with the following obligations and responsibilities:

1. We want students to be safe on the internet. Users are responsible for proper use of on-line accounts at all times. Users shall

keep private personal account numbers, home addresses, and telephone numbers.

2. 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.

3. Users shall not use the system to encourage the use of drugs, alcohol, or tobacco, nor shall they promote unethical practices or

any activity prohibited by law or University policy.

4. 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, religion or political belief.

5. Regarding e-mails, IMs and comments you might make to other COSMOS Students on their social networking site (like Facebook),

we require you:

a. To keep them positive and respectful of staff and students alike;

b. Not to use obscenities, vulgar or sexual language

c. Not to say mean or threatening things to or about other students or staff;

d. Not to pose as another student online, ever.

6. Most Internet communication is positive, and that’s great! In the rare case where there might be negative messages to other

students or staff, or other misuse of the internet, our policy is to inform parents of the misuse or content of negative messages, suspend internet privileges and, depending on the severity of the infringement, expulsion from the program.

7. Users shall not read others’ mail or files; they shall not attempt to interfere with other users’ ability to send or review electronic mail,

nor shall they attempt to delete, copy, modify or forge other users’ mail.

8. The internet contains material that may be considered harmful. The university will not knowingly allow the use of Internet for access to harmful matter. Because the university is a public place shared by students and staff of all ages, staff members reserve the right to end the Internet sessions when such material is displayed.

I understand and will abide by the provisions and conditions of this contract. I understand that any violations of the above provisions may result in the loss of my technology access privileges, dismissal from the program, and / or appropriate legal action.

Print Name of COSMOS Student Signature of COSMOS Student Date

I plan to bring my personal computer to COSMOS: YES NO

I have read this contract and I understand that it is impossible for the University of California, Santa Cruz to restrict access to all controversial materials, and I will not hold the University responsible for materials acquired on the network. I agree that my child’s inappropriate use of internet technology may result in the loss of technology privileges or dismissal from the program. I hereby give my permission for my child to access information utilizing the Internet.

Print Name of Parent/Guardian Signature of Parent/Guardian Date

Above signatures also indicate that signers will not hold UC Santa Cruz or COSMOS responsible for loss or damage to personal computers. Signers

fully accept the inherent risk in bringing private property to campus.

15 COSMOS 2017

Media Release Form

Student name:

The Regents of the University of California (“University") has my permission to photograph, videotape, audio

record, televise, duplicate, and/or transfer to any present or future technology, all or any portion of the event

described below, in which my child appeared:

Name of Event: COSMOS UC Santa Cruz Dates of Event: July 9-– August 5, 2017

Type of Event: Academic Summer Program Location: University of California, Santa

Cruz

I understand that my name, hometown or county, honors, photograph, and partial sections of my COSMOS

application or other COSMOS related work may be used for future COSMOS publications, including the

COSMOS yearbook. Further, I agree that the Regents of the University of California, its authorized agents,

employees, and assignees may reproduce, exhibit, publish, and/or distribute in such a manner as they deem fit,

the photographs, videotapes, student information, student projects, and/or audio recordings created during

COSMOS. No compensation will be paid for this use. This permission is granted on the understanding and

condition that the recording will be used only for purposes within the University's mission of teaching, research,

and public service.

• Indicating “No” will result in the removal of your child’s picture in the COSMOS yearbook, weekly

newsletters, and end of program slide show.

The University also intends to conduct a thorough program evaluation of this year’s Cosmos program. From

this evaluation we hope to learn about your child’s experience in COSMOS and the impact he/she thinks it has

had. We hope to use information to make modifications and improvements in future programs and to better

understand the ways in which the program affected its participants. During the evaluation, your child will be

asked to complete a brief questionnaire at the beginning and end of the program. Each questionnaire will take

about 30 minutes to complete. There are no risks to you or your child being involved in this evaluation. There

are no costs to you or your child beyond the time and energy required to participate in the evaluation process.

Although your child is not obligated to participate, we greatly value your participation. All information gathered

during this process will be anonymous.

As parent or legal guardian of the above named COSMOS participant, I give consent for my child to be

photographed, videotaped, or interviewed by news media doing stories for publication or broadcast about the

COSMOS program. My signature below also indicated my willingness to allow my child to participate in the

COSMOS evaluation.

Parent/Guardian Signature Date

Participant Signature Date

16 COSMOS 2017

Off-site Parental Permission form

I, do hereby provide my permission for (Print Name of the student attending the UCSC

COSMOS Program), herein referred to as Student, to spend time off campus for purposes unrelated to COSMOS.

I understand that there are certain risks and dangers inherent in Student’s time off campus during the program. I also

understand that in order for students to be allowed to spend time off campus without a COSMOS staff member, I must

give up both my rights and Student’s rights to hold the Regents of the University of California, its officers, agents, and/or

employees liable for any injury, property damage, and/or expense which said Student may suffer due to said student's

departure from campus.

I understand and agree that by signing this Release I am assuming full responsibility for any and all risks of death, personal

injury, and/or property damage to the Student while said Student is spending time off campus. I acknowledge that I have

read this UCSC Consent and Release Form (Release) and that I understand the words and language in it and agree to all of

it. I have been advised of the potential dangers incidental to Student while spending time off campus.

I certify that I am a parent or legal guardian of the minor referred above as the Student, and that I am signing this Release

on behalf of said minor Student.

Print Name of Parent/Guardian:

Signature of Parent/Guardian: Date Signed:

Off-site Check-In & Check-Out Guidelines

Parent/Guardian may pick-up and drop-off their child in person, or designate a responsible adult to pick-up/drop-off their

child during Check-In & Out hours. All check-ins and check-outs occur in the COSMOS main office by a COSMOS staff

member. Students may only be picked up or dropped off during the following check-in and check-out days and times:

Check-Out: Fridays: 4:00pm-7:00pm & Sundays*: 8:00am-10:00am

Check-In: Sundays: 8:00am-10:00am & 5:30pm-6:30pm

*Students will only be allowed to check-out Sunday mornings on the condition they return that same evening.

Students will not be allowed to check-out Sunday evenings. No Saturday check out or check in. No exceptions.

Please provide us with the names of designated adults, including parents, that are authorized to check-out (or visit) your

child on the weekends in the table below. (NOTE: We will not release your child to anyone who is not on the list below.)

If you don’t know the date/time, but think a designated adult may visit at some point please put them on the list.

Date Time Name (Designated Adult – ID will be checked)

*please be ready to present photo ID at checkout*

Phone # Relationship

17 COSMOS 2017

Health Facility Information Form

In the event a COSMOS participant needs medical attention, these are the available health care providers in Santa Cruz. We recommend you consult these providers to learn if your medical insurance is accepted at a certain location. Please indicate your preference on where your child should be taken on the form below.

*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.*

In a non-emergency situation, your preference in health care provider will be taken into consideration. Please indicate your choices:

Health Facilities

My child can visit this clinic Palo Alto Medical Foundation

Santa Cruz Center Urgent Care

If possible please take my child to another provider 2025 Soquel Ave Santa Cruz, CA 95062 Phone: (831) 458-5537 Hours: Everyday 8am-9pm Fees: Call http://www.pamf.org/urgent-care/santa-cruz-main/

My child can visit this clinic Doctor’s on Duty

615 Ocean Street

If possible please take my child to another provider Santa Cruz, CA 95060

Phone: (831) 425-7991; Fax: (831) 425-7346 Hours: Monday-Friday; 8am to 9pm; Saturday-Sunday; 8:30am-3pm Fees: Call http://doctorsonduty.com/locations/santa-cruz/

My child can visit this clinic Dominican Hospital – Emergency Room Only

1555 Soquel Drive

If possible take my child to another provider Santa Cruz, CA

Phone: (831) 462-7700 Fees: Call http://www.dominicanhospital.org/index.htm

My child can visit this clinic Dignity Health/Dominican Urgent Care

1820 41st

Ave., Ste. C.

If possible take my child to another provider Capitola, CA 95010 Phone: (831) 684-7611 Hours: Open Daily 12pm-8pm

http://www.dignityhealth.org/medical- groups/california/dominican/services/urgent-care

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, a n d when in the judgment 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.

Signature Date: Time:

Parent / Legal Guardian / Person Having Legal Custody (circle relationship)

COSMOS at UC Santa Cruz 1156 High St. California State Summer School for Mathematics & Science Santa Cruz, California 95064

Educational Partnership Center Tel: 831-459-1766 Fax: 831-459-3570

Confidential Health History Form (1 of 2) Student Name Last First Gender: M F DOB:

PRINT PRINT MM/DD/YYYY

Cluster # and title:

Parent/guardian who holds insurance coverage for student:

Insurance Holder’s Address

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:

Confidential Health History Form (2 of 2) MEDICATIONS – Student is required to store prescription and over-the-counter medications in original containers with

written instructions and is responsible to administer dosage according to instructions. ARE YOU TAKING ANY MEDICATIONS? YES NO If yes, please specify below:

AUTHORIZATION FOR TREATMENT

Instructions: In the event of an emergency, UC Santa Cruz 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 N a m e :

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 Santa Cruz 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 Santa Cruz 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

University of California Immunization Plan July 2016

The University of California is committed to protecting the health and well‐being of our students. Therefore, all of the

UC campuses are implementing procedures to ensure that students are educated about and receive vaccinations to

prevent potentially serious and contagious diseases. Despite the fact that many people do receive the

recommended vaccines, there are still documented outbreaks of vaccine‐preventable‐diseases (VPD) in California

each year amongst those who were not completely immunized.

California Dept. of Public Health IMMUNIZATION & SCREENING RECOMMENDATIONS All COSMOS students must obtain all listed vaccines prior to starting classes.

Vaccination Doses

Measles, Mumps and Rubella (MMR) 2 doses; first dose on or after 1st

birthday

Varicella (chickenpox) 2 doses; first dose on or after 1st

birthday

Tetanus, Diphtheria and Pertussis (Tdap) 1 dose in the last 10 years.

Meningococcal conjugate (preferred

to polysaccharide vaccine)

One dose on or after age 16.

Hepatitis B

3 doses

(CURRENTLY HEPATITIS B VACCINE IS REQUIRED FOR ALL

STUDENTS UNDER THE AGE OF 19.)

Screening for Tuberculosis

All incoming students who are at higher risk for TB

infection should undergo either skin or blood testing for

TB infection. (Higher risk includes travel to or living in

South & Central America, Africa, Asia, Eastern Europe,

and the Middle East; prior positive TB test, or exposure

to someone with active TB disease.)