INSTRUCTIONS FOR COMPLETING REGISTRATION. 2. Fill out the forms completely with necessary information and signatures:

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2 INSTRUCTIONS FOR COMPLETING REGISTRATION 1. Print out the Waiver of Liability, Medical Release Form and Participant Information Sheet attached to this document 2. Fill out the forms completely with necessary information and signatures: 3. Return Completed Forms to the EAOP office no later than Wednesday, July 8th, 2015 Via Mail or Drop Off: Early Academic Outreach Program University of California, Riverside 1228 Student Services Building 900 University Ave Riverside, CA Via Fax (951) Via Scan & 4. Print, complete and bring your completed answers for the Writing the Personal Statement worksheet to the Senior Summit Orientation you registered for.

3 UNIVERSITY OF CALIFORNIA, RIVERSIDE Waiver of Liability, Assumption of Risk, and Indemnity Agreement EAOP SENIOR SUMMIT (Wednesday, July 29- Friday July 31, 2015) Waiver: In consideration of being permitted to participate in any way in General Services for the Early Academic Outreach Program until completion of high school (Academic Advising, Tutoring, Campus Tours, Specialized Workshops) 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 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 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 paragraphs 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 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 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 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. Participant's Age (if minor) Vol Waiver 7/01

4 University of California, Riverside Early Academic Outreach Program SENIOR SUMMIT 2015 RELEASE FOR EMERGENCY MEDICAL TREATMENT AND MEDICATION AUTHORIZATION (PLEASE PRINT) Student Name: Name of School he/she attends: Grade Parent s/guardian s Name: Home Phone: ( ) Work/Emergency Phone: ( ) Insurance Company: Policy Number: The program provides an excess Accident insurance policy for each participant. The coverage payable under the University s policy is in excess of any other valid and collectible medical insurance that is in force on a participant. I do I do not permit my child to be given aspirin or Tylenol when necessary. (Please check one) I authorize the use of the following medication(s): Please list under what condition medication is to be taken and instructions for its use: Print Parent/Guardian Name Date Parent/Guardian Signature

5 Participant s Name: Print Name UNIVERSITY OF CALIFORNIA AT RIVERSIDE OUTDOOR EXCURSIONS - STUDENT RECREATION CENTER Waiver of Liability, Assumption of Risk, and Indemnity Agreement Waiver: In consideration of being permitted to participate in any way in Outdoor Excursions activity (herein after known as Team Excursions ), on / 20 through / 20. 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 Team Excursions activities. Assumption of Risks: Participation in Outdoor Excursions activities 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 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 the activities made possible by Outdoor Excursions. 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 Outdoor Excursions activities 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. Participant s Age (if minor) Elec Vol 5/01

6 Challenge Course Participant Information Participant Name: Date: Address: City: Home Phone: Work Phone: Date of Birth: CONFIDENTIAL HEALTH INFORMATION All items must be completed. If not, the person above will not be permitted to participate. List allergies, if any: (i.e. bug bites, drugs, food, etc. Note: counteractive medications should be carried at all times.) Medication(s): List any serious illness or injury experienced within the past 3 years: List any current medical conditions: (i.e. Asthma, Diabetes, Epilepsy, heart conditions, etc.) List all conditions that may affect ability to participate: (i.e. history of cardiac conditions in the family, etc.) Do you have any conditions or limitations for which you are currently under doctor s care? EMERGENCY CONTACT 1. Name: Relationship: Home Phone: Work Phone: 2. Name: Relationship: Home Phone: Work Phone: Do you carry medical insurance? Yes No Group Number: Provider:

7 This worksheet is meant to help you narrow your focus for each prompt. On a separate sheet of paper, answer the questions below while thinking about the context of the two prompt. PROMPT #1 Describe the world you come from for example, your family, community or school and tell us how your world has shaped your dreams and aspirations. PROMPT #2 Tell us about a personal quality, talent, accomplishment, contribution or experience that is important to you. What about this quality or accomplishment makes you proud and how does it relate to the person you are? What are your short-term goals? What are your long-term dreams and aspirations? How have your dreams and aspirations been shaped by your o Family: Are you an only child or do you come from a large family? Do you have an important role to play in your family? Are you the first person in your family to go to college? How does your family interact with one another? o Community: What type of community do you belong to? What are the challenges or opportunities that exist in your community? Does culture play an important role in your community? o School: What academic, extra-curricular or other opportunities have been available to you? Is it common for students to go college at your high school? What type of culture exists in your high school? How does this relate to your success in college? What are you most proud of about yourself? How does this relate to the person you are? What do you consider one of your strengths? What are you good at? What have you done to develop your career interests? o Community Service/Volunteer o AP/Honors Courses o Work/Internships o Clubs/Organizations o College Prep Programs (EAOP, etc.) How does this relate to your success in college? The Personal Statement is your interview with the University of California. The UC is not looking for a specific writing style; they are looking for content. Your response should add clarity, depth and/or context to the application as a whole Be You. Use plenty of I Statements. Avoid Clichés. Talk about yourself so that UC can get to know your personality, talents, accomplishments and potential success on a UC campus.