Acceptance Packet Forms Checklist

Updated 3/28/18- JRP

Thank you for downloading the Acceptance Packet Forms. Please be sure to complete and sign all forms and return them to the address below with your non-refundable deposit, housing security/cleaning deposit check and your Acceptance Confirmation. All forms and confirmation of the non-refundable security deposit must be received by April 11, 2018.

J. Richard Pomeroy, Director UCD-Young Scholars Program School of Education, University of California One Shields Avenue Davis, CA 95616-8579

• Program Costs and Payment Information • Online Payment Instructions • Payment Coupons • Medical Form • FERP Rights Form • UCD Young Scholars Expectations • Acceptable Use Policy • Digital Communications and Social Media Policy • UCD-YSP Photo Release Form • Survey Consent Form • Bodega Bay Marine Lab Waiver Form • Project Checklist for Minors Performing Research in Laboratories • Minors in Lab Rules • Minors in Lab Release of Liability • Work permit application • Frequently Asked Questions for International Students (Non-US Citizens or non-permanent

residents. The Acceptance Packet Forms include the Payment Information and Payment Instructions. These forms need not be returned. Please make copies of all forms for your files.

UCD- YSP Payment Information 2018

Program Costs

Congratulations on your acceptance to the 2018 UCD-Young Scholars Program. The cost for the program for the summer of 2018, including 5 units of University group study credit, is $6500*. This fee covers room and board, weekend field trips, and all program costs for the duration of the program (June 24- Auguat 4, 2018). This amount is broken down into a $2500* NON-REFUNDABLE Deposit ($2475 + $25 application fee) and balance of $4000. The non-refundable deposit MUST be paid in the form of a money order, certified cashiers check or online credit card payment. NO PERSONAL CHECKS CAN BE ACCEPTED FOR THE NON-REFUNDABLE DEPOSIT. Please use the enclosed payment coupons for all payments. If you pay online, please include a copy of your payment confirmation including the transaction number. In addition to the $2500 non-refundable deposit, there is a $200, fully refundable housing security deposit due with your first payment and acceptance package forms. Please be sure that the housing deposit is in the form of a SEPERATE PERSONAL CHECK. Assuming that no keys are lost or damaged, no damage is done to the dorm room, and all materials have been returned, this deposit will be returned to you. Your non-refundable deposit and housing security deposits are due by the close of business on April 11, 2018. Payment in full is due by the close of business, June 1, 2018. *If you requested a fee reduction at the time of your application, please adhere to the dollar amounts shown in your award letter email.

Performance Guarantee If for some reason you must withdraw from the program after paying your non-refundable deposit, but

prior to May 11, 2018, every effort will be made to fill your place in the program. If a candidate can be found to take your place (secured by a non-refundable deposit) at the full fee level, your deposit will be returned minus a $500 refund fee. If no one can be found to fill your place, the non-refundable deposit will be forfeited. If you withdraw after May 11, 2018, you will forfeit the entire non-refundable deposit. University Credit

All students will receive 5 units of University group study credit. The cost for these credits is included in the total cost of the program.

Bicycle Rental Students wishing to rent a bicycle for the six weeks of the program may do so at the ASUCD Bike

Barn. Cost for bike rental for 6 weeks is $175. Students who choose to rent a bike will be escorted to the bike barn by our program staff on the first Monday of the program. Payment for bike rentals, in the form of cash or personal check made out to UCD-YSP, will be accepted on the first day of the program and is not included in the cost of the program.

Medical Insurance Each participant’s family is responsible for providing medical insurance for the duration of the program. Please make sure that your insurance is valid for the duration of the program.

UCD- YSP Payment Information 2018

Payment Schedule April 11, 2018 - $2500 Non-Refundable Deposit Due ($2475 + $25 Application Fee) Payment may be made by Cashier’s Check or online credit card payment June 1, 2018 - $4000 Total balance due Payment may be made by cashier’s check or online credit card payment. You may make partial payments at any time between April 11th and June 1st if you choose. Please use the payment coupons for each payment. Please include a copy of any online payment confirmations including the transaction number. Address for mailed payments J. Richard Pomeroy, Executive Director UC Davis –Young Scholars Program School of Education University of California One Shields Avenue Davis, CA 95616-8579 * If you have been granted a fee reduction, please follow the directions in your award email.

UC Davis – Young Scholars Program Online Payment Instructions

To make an online credit card payment, follow these instructions:

1. Log into your account on http://ysp.ucdavis.edu 2. You will see a payment block like the table below on the left side of the home page.

YSP Payments Awards and reductions: $ 0.00 a. Fee reductions and Application fee waivers Amount received from you: $ 25. b. This box contains the amount you have paid Non-refundable deposit: $ 0.00 c. This is the amount of the non-refundable deposit you owe Total balance: $ 0.00 d. This is the amount due by June 1st.

3. To pay the non-refundable deposit, click on the “Pay now via credit card” link at the bottom of the block and follow the online payment instructions.

4. Complete the information on the secure payment site 5. Be sure to retain a copy of your payment confirmation for your records 6. Once the online credit card payment has been received, the “Total balance due” will change

from $6500 to what you still owe. 7. After paying the non-refundable deposit, you can pay your “balance due” in as many

payments and at any time in any amount you want as long as the balance is paid in full by the close of business on June 1, 2018.

8. If you choose, you may pay the non-refundable deposit and balance due with cashier’s checks or certified checks. No personal checks can be accepted for the non-refundable deposit or balance due. If you choose this option, please mail the cashier’s or certified checks with the payment coupons included in the Acceptance Package Forms.

9. A housing deposit of $200 in the form of a personal check made out to UCD-YSP must accompany the mailed in Acceptance Form regardless of the method you choose for paying the non-refundable deposit.

Mail all materials to: J. Richard Pomeroy, Executive Director UC Davis Young Scholars Program School of Education One Shields Avenue Davis, CA 95616-8579

Please separate and include ONE of the attached payment coupons with each payment. If paying online, by credit card, please include a copy of the transaction confirmation with the transaction reference number. Please complete all of the information on the form for each payment. All fields must be completed so that we can process your payment information. Upon receipt, these forms will be kept in our accounting office to protect your privacy.

Payment #1-Non Refundable Deposit DUE April 11, 2018

Student’s name: ___________________________________ Student User ID#: ________________________ Home Address: _____________________________________________________________________________ Home Phone: __________________ Work Phone: __________________ Cell Phone: ____________________ Parents’ email address: ______________________________________ Housing Security Deposit ($200 Personal Check ONLY): _______________ Non-Refundable Deposit ( $2500 No Personal Checks) Amount of payment: _______________

Please Make Checks Payable to UCD-YSP

_____ Check here if non-refundable deposit paid at online credit card site. Payment transaction number: _________________________________ Amount of payment: _______________ ------------------------------------------------------------------ Cut Here ------------------------------------------------------------------------

Payment #2

Student’s name: ___________________________________ Student User ID#: ________________________ Home Address: _____________________________________________________________________________ Home Phone: __________________ Work Phone: __________________ Cell Phone: ____________________ Parents’ email address: ______________________________________ Online payment transaction number: _________________________________ Amount of payment #2: _______________ ------------------------------------------------------------------ Cut Here ------------------------------------------------------------------------

Final Payment - DUE June 1, 2018.

Student’s name: ___________________________________ Student User ID#: ________________________ Home Address: _____________________________________________________________________________ Home Phone: __________________ Work Phone: __________________ Cell Phone: ____________________ Parents’ email address: ______________________________________ Online payment transaction number: _________________________________ Amount of final payment #3: _______________

UCD-YSP Authorization to Consent to Treatment of a Minor

and Emergency Contact Information

I/We, the undersigned guardian(s) of ____________________________________________________________, a minor, do hereby authorize J. Richard Pomeroy, Megan Bettis or their Designee to act as an agent for the undersigned and to give informed consent to any medical treatment which is deemed advisable by licensed physicians practicing at Cowell Student Health Center or local medial facilities. It is understood that this authorization is given in advance of any specific diagnosis or treatment being required, but is given to provide authority and power on the part of our aforesaid agent to give informed consent. It is our understanding that we will be contacted in the event of illness or injury if at all possible. This authorization shall remain effected between June 24 through August 4, 2018, unless sooner revoked. Guardian name (printed): ________________________ Relationship: ____________________________ Guardian signature: ____________________________ Date: _______________________________ Guardian contact information Home phone: __________________ Address: _______________________________________ Business phone: ________________ City: ___________________ State: _________________ Mobile phone: _____________________ Zip Code: ____________________________ Emergency contact (if primary guardians cannot be reached) Name (printed): ______________________ Relationship: _______________________________ Phone #1: __________________________ Phone #2: ________________________________ Insurance information Is your child covered by medical insurance? _________ Yes _________ No If “YES”:

Insurance Company:________________________________________________________________ Company or Group: _________________________________________________________________ Address:__________________________________________________________________________ Name of Insured:___________________________________________________________________ Policy/Group Number: ______________________________________________________________ Policy/Group Number: ______________________________________________________________

Special conditions for use of insurance: ________________________________________________________________________________________

UCD-YSP Medical History To be completed by parent/guardian. Attach additional paper if necessary. Scholar’s Name: ____________________________________________ DOB: ___________ Scholar contact information Mobile phone: ________________________ Address: __________________________________________ Summer email: _______________________ City: ____________________ State: _________________

Zip Code: ____________________________ Physician information Physician: ____________________________ Date of latest physical examination: _____________________

Physician address: _______________________________________________________________________

Physician phone number: _________________________________ Is your child presently under physician’s care? _________ Yes_________ No If yes, please describe below. May we contact the physician if necessary? _________ Yes _________No Medical history Does your child have medical problems or has he/she been seriously ill or hospitalized in the past three year?

_________ Yes _________ No If yes, please describe below. Are there limits to your child’s physical activities?

_________ Yes _________ No If yes, please describe below. Is your child have any dietary restrictions, including vegetarian or vegan?

_________ Yes _________ No Describe specific dietary restrictions below? Date of last tetanus immunization: _____________ Can your child swim? _________ Yes _________ No Does your child wear contacts? _________ Yes _________ No Does your child carry an inhaler? _________ Yes _________ No Does your child carry in epi-pen? _________ Yes _________ No Please describe any pertinent medical history, drug, food, or environmental allergies, previous illness/injury, activity or dietary limitations, etc. Attach additional pages if necessary. _______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

UC Davis-Young Scholars Program FERPA Rights

I understand that the Family Education Rights and Privacy Act of 1974 (FERPA), as amended, affords students the right to authorize the release of education information to third parties. I also understand that studying special programs /off campus may involve circumstances which require UC Davis to release certain information to third parties, but for which it may be difficult to obtain my prior written permission. For these reasons, I herewith authorize university officials to release my education information to parties, who, in their judgment have an interest in the special program/off campus contemplated by this document provided that those officials, in their judgment, are acting in my interest as well. This authorization is valid from the time I signed document to Summer Sessions Special Program through a period of one quarter after my program ends.

Participant’s signature required Date

UC Davis Young Scholars Program Expectations

Updated 3/28/18- JRP

The Young Scholars Program is an intense six-week experience with many new and exciting opportunities. It is the goal of program staff to insure each student’s experience is the best possible. In order to insure this, participants must understand that ground rules and expectations, established by the University, and program staff, are required. UCD-YSP participants agree to abide by these rules and expectations. Repeated or willful violation of the rules and expectations, open defiance, disrespect of staff, lab personnel, or faculty, or willful destruction of University property will result in removal from the program with a grade of Not Passed (NP). • All work in the UCD-YSP is graded. Grades will be based on student participation, assignments, lecture exam,

research paper, research presentation, and final home school presentation. Grades will be issued upon completion of the home school presentation. Students failing to complete the home school presentation by December 31st will receive a grade of Not Passed. (NP).

• UCD-YSP participants are not allowed to ride with drivers other than their parents, guardians, UCD-YSP staff or, with permission, their research team.*

• UCD-YSP participants are not allowed to have motor vehicles under any circumstances. • UCD-YSP participants are not allowed to use tobacco, alcohol, or other illegal drugs.* • UCD-YSP participants will have a curfew each night as follows:

o Participants are in the dorm by 10PM and in their rooms by 11PM. • When leaving the dorms for activities other than lab, meals, or organized program activities participants must sign

out and be accompanied by at least two other participants of the UCD-YSP unless prior arrangements have been made in advance with the Program Director or Assistant Director. When leaving with staff, three people must be present.

• When males and females are in a room together, the door must remain fully open. • Non UCD-YSP visitors, other than immediate family, are permitted in the first-floor lounge and entry hall areas of

the dorm only. No overnight visitors will be allowed.* • Intimate relations are not allowed.* • UCD-YSP participants are expected to be on time to all activities. • UCD-YSP participants will adhere to all UCD-YSP, University of California, Davis, and University Conference

Housing rules and regulations as well as the applicable civil codes of the City of Davis and the State of California. • Research mentors have graciously agreed to host UCD-YSP participants in their labs for the duration of the

program. The participant agrees to work as a colleague with others in the lab recognizing that they are guests in the lab group.

Failure to comply with the rules indicated with an * will result in immediate dismissal from the program with no refund. Repeated violations of any rules or expectations may lead to dismissal from the program with no refund.

I have read and discussed these expectations with my parents and I agree to abide by the expectations as stated above. X ___________________________ ___________ X _____________________________ _________ Participant signature Date Parent Signature Date

UC Davis Young Scholars Program Acceptable Use Policy

Parent and Scholar,

As a participant in the UC Davis - Young Scholars Program, you will have access to a wide

variety of technologies and resources during your work on campus. The program dormitory computer facility and your labs will have computers that are connected directly to the Internet. It has been widely publicized that the Internet is an unregulated medium and as such may contain material that would be deemed inappropriate for minors. It is unrealistic to believe that any member of the UC Davis Young Scholars Program staff can directly monitor your use of the Internet during the program. Therefore, it is your responsibility to use these resources solely for the purposes of your research or personal communication. Downloading of material not directly associated with your research is an inappropriate use of campus computers and is not allowed. Should you happen upon a site that would be unacceptable for use in a public school you should immediately exit that site. It is your responsibility to avoid or exit inappropriate sites. Should you choose to visit inappropriate Internet sites or download non-research related materials during the program, you will receive one warning to stop such activities. After that, continued visitation to inappropriate sites or downloading of material not associated with your research will be grounds for dismissal from the program with no refund. In order to verify your understanding of this policy, please sign in the space below and return this document with your Confirmation Form and Non-Refundable Deposit.

J. Richard Pomeroy, Executive Director, UCD-YSP I have read and understand the conditions for use of the Internet as described above.

Participant signature Parent or Guardian signature Date

Social Media Policy 2018

Update 3/28/18 - JRP

Digital communications and social media, (text messages email, Facebook, Edmodo, Twitter, Instagram, Snapchat etc.) have become a daily part of our lives. Instant communications can be a powerful way to reach a wide range of individuals quickly. It is also an area of concern in that once a message, image, or comment is posted, it develops a life of its own that can be very long lasting. In consideration of the power, both positive and negative, of digital communications and social media the UC Davis - Young Scholars Program has or will establish official channels for use by our staff and participants during and after the program. These portals currently exist (Facebook: Young Scholars Program at UC Davis) or they will be created and announced at the start of the program. The rules and policies associated with digital communications and social media will remain in effect for staff and participants for one year after the conclusion of the program. Person to Person Communications

• All person-to-person digital communications (email and text etc.) initiated by staff will be cc’d or group texted to include at least one additional member of the YSP staff for archival purposes.

Social Media

• Staff postings to social media sites (Facebook, Twitter, Instagram etc.) will be to the official program sites only. Program administration reserves the right to monitor and edit all postings in the best interest of participants, the program, and the University.

• Images posted to social media sites will be monitored by program staff to respect participants, research, and privacy.

• UCD-YSP will maintain the official YSP website as the official source of program information. Postings to other social media sites should be verified on the official YSP website (http://ysp.ucdavis.edu)

• Students posting images from the program on their own social media sites are asked to respect the privacy and feelings of others in the pictures. UCD-YSP retains the right to monitor images where logos, or other identifiers of the program are visible in images, text, or sound and the right to request that images be removed if they reflect poorly on individuals, research or the program.

o Failure to comply with program requests to remove images could result in dismissal from the program.

• No images from research placements may be posted without written permission of the Principle Investigator.

I have read and understand the Social Media Policies described above and agree to abide by these policies for the duration of the program plus one year.

Participant signature Parent or Guardian signature Date

UC Davis Young Scholars Program Photo Release Form

Authorization & Consent for Use of Name, Voice, and Likeness

Dear Participant/Parent, As one of the ongoing projects in the UC Davis Young Scholars Program, we will be posting pictures to a website and/or Facebook on a regular basis. This website is intended for parents, family members, potential applicants, and the greater community to see a brief glimpse of the activities of the participants in UCD-YSP. We would like your permission to post you/your child’s pictures to our website/Facebook page as they participate in program activities. Photos will only be taken during public portions of the program such as the lecture series, lab work, field trips, and activities. Only students’ first names will be included with the web photos. In addition, we may send a press release to each students’ hometown newspaper with a photo of that student doing their research, for which we need your permission. All newspaper photos will be taken by the program staff, the media consultant for the UCD School of Education, or a photographer from the participant’s hometown newspaper. Participants may independently create a photo-sharing site. UCD-YSP staff and the School of Education have no control over individuals’ postings on non-sponsored sites. If you grant your permission to use pictures of you/your son/daughter (if they are under 18 years of age) for these purposes, please read and sign the form below. Thank you in advance for your cooperation, J. Richard Pomeory, Executive Director UCD-YSP I hereby authorize and consent to the use of my/my child’s name, voice, photograph and likeness by The Regents of the University of California without reservation or imitation. As used herein, “photographs” shall include any photograph, photographic reproduction or facsimile, still or moving, or any videotape or live transmission, or any recordings thereof. The undersigned agrees to receive no compensation. Property rights to any photographs of the undersigned produced or prepared by The Regents of the University of California, or any agent thereof, pursuant to this authorization and consent, shall vest in and remain with The Regents of the University of California. Said photographs of the undersigned may be used via print, the Web and any over-the-air and/or closed circuit broadcast transmission facility. The undersigned by his/her signature below waives any cause of action for personal injury and/or property damage by virtue of the taking and use of photographs herein described by The Regents of the University of California. This authorization and consent shall be binding upon the undersigned heirs, successors licensees, agents and assigns, and shall be governed by the laws of the State of California. I give my permission to use ______________________________________________________________’s picture/likeness for the purposes described above. (Participant’s Name) ______________________________________________________________ __________

(Participant/Parent’s Signature) (Date)

Survey Consent Form 2018

Dear Parent and Participant,

The goals of the UCD-YSP are to acquaint participants with scientific research and university life through a six-week summer residential research program. As part of this program, participants will live in university dorms, attend formal and informal lectures and presentations, and conduct research as members of the university research community.

In order to monitor the effectiveness of the program in meeting its goals, participants and parents may be asked to respond to brief questionnaires or surveys before, during, and after the program. The surveys will be administered by program staff and will be used for the purposes of determining the efficacy of the program and ways to improve the program for future years. No more than three surveys or questionnaires will be distributed. Responses to these surveys will be held in the strictest confidence and will not be used for any other purpose.

Prior to completing the first survey, all participants will be given the opportunity to pick a unique identification code. Participants will be asked to use that code on all subsequent questionnaires. For the purposes of confidentiality, a record of that unique identification code will be kept by a faculty member in the School of Education who is not associated with the program. The codes will only be revealed after final grading has been submitted and then only to allow for analysis of the survey results.

Survey results will not be identified by individual participants nor will they be used in any way for selection, project matching, or grading. All participants will remain anonymous in any and all reports prepared from the survey information.

• Participants have the right to not participate in the surveys if they so choose. • Participants have the right to receive copies of any reports prepared from the information

gathered in the surveys when such reports have been completed. Your signature in the spaces below indicates your voluntary willingness to complete the surveys and

questionnaires described above.

Participant Date Parent Date

Thank you for agreeing to assist us in evaluating the program for the purposes of meeting studentsʼ needs and providing the best program possible in future years. If you have any questions, please do not hesitate to contact the Executive Director at (530) 574-0289 or via email at jrpomeroy@ucdavis.edu

J. Richard Pomeroy, Executive Director UC Davis Young Scholars Program

Participant’s Name (Print):

Participant’s Age (If Minor): NRS Waiver 3/01

UNIVERSITY OF CALIFORNIA, DAVISBODEGA MARINE RESERVE

Waiver of Liability, Assumption of Risk, and Indemnity Agreement

Waiver: In consideration of being permitted to visit or participate in any way in any activity,including transportation, at the above location, I, for myself, my heirs, personalrepresentatives or assigns, do hereby release, waive, discharge, and covenant not to sueThe Regents of the University of California, its officers, employees, and agents from liabilityfrom any and all claims including the negligence of The Regents of the University ofCalifornia, its officers, employees, and agents, resulting in personal injury, accidents orillnesses (including death), and property loss arising from, but not limited to, visitation orparticipation in any way in any activity, including transportation, at the above location.

Signature of Minor’s Parent/Guardian Date Signature of Participant Date

Assumption of Risks: Visitation or participation carries with it certain inherent risks thatcannot be eliminated regardless of the care taken to avoid injuries. The specific risks varyfrom 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 backinjuries, heart attacks, and concussions to 3) catastrophic injuries including paralysis anddeath.

I have read the previous paragraphs and I know, understand, and appreciatethese and other risks that are inherent in visitation or participation. I hereby assert thatmy visitation or participation is voluntary and that I knowingly assume all such risks.

Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD TheRegents 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 aresult of my involvement in visitation or participation and to reimburse them for any suchexpenses incurred.

Severability: The undersigned further expressly agrees that the foregoing waiver andassumption of risks agreement is intended to be as broad and inclusive as is permitted by thelaw of the State of California and that if any portion thereof is held invalid, it is agreed thatthe balance shall, notwithstanding, continue in full legal force and effect.

Acknowledgment of Understanding: I have read this waiver of liability, assumption ofrisk, and indemnity agreement, fully understand its terms, and understand that I am givingup substantial rights, including my right to sue. I acknowledge that I am signing theagreement freely and voluntarily, and intend by my signature to be a complete andunconditional release of all liability to the greatest extent allowed by law.

Signature of Minor’s Parent/Guardian Date Signature of Participant Date

Section 290-32 Exhibit B 8/25/08

Project Checklist for Minors Performing Research in Laboratories

Minor’s Name: _____________________________________________________________

Date of Birth: ______________________________________________________________

Supervisor: __________________Megan Bettis or her designee__________________

Principal Investigator ___________To Be Assigned _________________________________

Time Frame of Research Project: June 24-August 4, 2018__________________________

_ X _ Check here if this minor will be participating in a research laboratory project

___ Check here if this minor will be participating in a classroom or educational outreach program.

Project Summary and types of experiments to be performed:

Students may be engaged in laboratory research and or fieldwork, creating, collecting, and or processing samples, on a daily basis. Under the direct supervision of research faculty and or laboratory personnel, projects may involve computer modeling, molecular biology, chemistry, ecology, engineering and or environmental systems. All students will participate in both online safety training prior to the start of the program and in person laboratory safety and procedures orientation as part of the program orientation. Any additional required training will be provided based on the exact nature of the research project. Minor’s prior research experience: (Please describe briefly)

Approved exceptions to guidelines (requires approval of appropriate Committee/s)

Any required approvals will be obtained before the start of work.

Signatures (must be completed prior to beginning work):

Minor: __________________________ Parent or Guardian: ____________________________

PI: ___Will be obtained before beginning work _____________________________________________

Supervisor: (If different than PI will be obtained before beginning work) ____________________________

EH&S Officer(s) below:

CHO __________________________________________________________________________

BSO __________________________________________________________________________

RSO __________________________________________________________________________

RULES FOR MINORS IN LABORATORIES AND SHOPS

1. Never participate on a scheduled assignment alone in any laboratory environment without direct, immediate adult supervision from the sponsor or someone designated by the sponsor.

2. Complete and follow safety training specific to the hazards in the laboratory. 3. Always wear the personal protective equipment as directed and dispose of it appropriately. This

personal protective equipment (PPE) includes goggles, gloves, coats/gowns, and other face/body protection as dictated by the hazard being worked with or around. Always remove PPE when leaving the work area.

4. Always follow the instructions of the sponsor or laboratory supervisor. 5. Always report any accident (regardless of severity) immediately to the sponsor or laboratory

supervisor. 6. Always keep your hands away from your face and wash them well with soap and water prior to

leaving any laboratory area and after removing gloves. 7. Never eat, drink, chew gum, apply lip balm, or touch contact lenses while in any laboratory

environment. 8. Always wear closed-toe shoes while in any laboratory. 9. Always tie back long hair to keep it out of all the hazards listed above. 10. Always wear clothing that reduces the amount of exposed skin. 11. Always ask questions if you don’t understand the safety requirements.

_____________________________________ Printed Name of Minor Child ___________________________________ Signature of Minor ___________________________________ ___________________________________ Signature of Parent/Legal Guardian Printed Name of Parent/Legal Guardian ________________________ Date

Page 12 of 13

RELEASE OF LIABILITY, WAIVER OF CLAIMS, EXPRESS ASSUMPTION OF RISKS, AND HOLD HARMLESS AGREEMENT

I HAVE READ, UNDERSTAND, and INITIALED the documents Rules for a Minors Working in Laboratories and Shops and Potential Hazard Information Sheet describing the potential risks and dangers associated with my child’s research project. I fully understand that there are potential risks and hazards associated with exposure to hazardous materials or substances. I AGREE TO ALLOW my minor child to participate on a scheduled assignment in the University of California laboratories and freely accept and assume all associated risks and hazards. I ALSO AGREE AND UNDERSTAND that my child’s research project may be suspended at any time, at the discretion of the University of California and its officers, agents, and employees, if the safety of my child, University of California employees and/or other volunteers at the University of California become a concern. I, for myself and my estate, heirs, administrators, executors, and assigns, hereby release and hold harmless the State of California, the UC Board of Regents, and their officers, directors, employees, representatives, agents, and volunteers (collectively, the “Releases”), from any and all liability and responsibility whatsoever, however caused, for any and all damages, claims, or causes of action that I, my estate, heirs, administrators, executors, or assigns may have for any loss, illness, personal injury, death, or property damage arising out of, connected with, or in any manner pertaining to my child’s scheduled assignment in the University of California laboratories, whether caused by the negligence of Releases or otherwise. I further hereby agree to defend, indemnify and hold harmless the Releases from any judgment, settlement, loss, liability, damage, or costs, including court costs and attorney fees that Releases may incur. In signing this agreement, I acknowledge and represent that I have read and understand it and that I sign it voluntarily and for full and adequate consideration, fully intending to be bound by the same. _____________________________________ Printed Name of Minor Child _____________________________________ ________________________________ Signature of Parent/Legal Guardian Printed Name of Parent/Legal Guardian ________________________ Date I have read, understand, and will adhere to the University of California Minors in Laboratories and Shops Policy. I understand that failure to comply with this Policy is dangerous to my health and safety and that I may be removed from the facility immediately for any failures or deviations in compliance. ___________________________________ Signature of Minor ___________________________________ Date

Page 9 of 13

Copy–District or County Superintendent; Employer; Parent or Legal Guardian (Over)

STATE OF CALIFORNIA DEPARTMENT OF EDUCATION STATEMENT OF INTENT TO EMPLOY A MINOR AND REQUEST FOR WORK PERMIT– CERTIFICATE OF AGE CDE B1-1 (Rev. 07-10) A “STATEMENT OF INTENT TO EMPLOY A MINOR AND REQUEST FOR WORK PERMIT–CERTIFICATE OF AGE” form (CDE B1-1) shall be completed in accordance with California Education Code 49162 and 49163 as notification of intent to employ a minor. This form is also a Certificate of Age pursuant to California Education Code 49114. (Print Information)

Minor’s Information

Minor’s Name (First and Last) Home Phone

Birth Date Social Security Number Grade Age

Home Address City Zip Code

School Information

School Name School Phone

School Address City Zip Code

To be filled in and signed by employer. (Please review the General Summary of Minors’ Work Regulations on reverse.) UC Davis School of Education (530) 574-0289 Megan Bettis

Business Name or Agency of Placement Business Phone Supervisor’s Name One Shields Avenue Davis, CA 95616

Business Address City Zip Code Describe nature of work to be performed: Participate in unpaid laboratory research project associated with EDU 098

In compliance with California labor laws, this employee is covered by worker’s compensation insurance. This business does not discriminate unlawfully on the basis of race, ethnic background, religion, sex, sexual orientation, color, national origin, ancestry, age, physical handicap, or medical condition. I hereby certify that, to the best of my knowledge, the information herein is correct and true.

J. Richard Pomeroy

6/24/2018 Employer’s Name (Print First and Last) Employer’s Signature Date

To be filled in and signed by parent or legal guardian This minor is being employed at the place of work described with my full knowledge and consent. I hereby certify that to the best of my knowledge and belief, the information herein is correct and true. I request that a work permit be issued.

Parent or Legal Guardian’s Name (Print First and Last) Parent or Legal Guardian’s Signature Date

For authorized work permit issuer use ONLY

Maximum number of hours of employment when school is in session:

Mon Tue Wed Thu Fri Sat Sun Total

Check Permit Type:

*Full-time

**Workability

Restricted

General

***Work Experience Education, Vocational Education, or Personal Attendant

Proof of Minor’s Age (Evidence Type)

Verifying Authority’s Name and Title (Print) Verifying Authority’s Signature

*EC 49130 | **Permit Type defined by local school |***Special Education Grant

STATE OF CALIFORNIA DEPARTMENT OF EDUCATION STATEMENT OF INTENT TO EMPLOY A MINOR AND REQUEST FOR WORK PERMIT— CERTIFICATE OF AGE CDE B1-1 (Rev. 07-10)

General Summary of Minors’ Work Regulations FLSA-Federal Labor Standards Act, CDE-California Department of Education, EC-California Education Code, LC-California Labor Code, CFR-California Federal Regulations

• If federal laws, state laws, and school district policies conflict, the more restrictive law (the one most protective of the minor) prevails. (FLSA)

• Employers of minors required to attend school must complete a “Statement of Intent to Employ a Minor and Request for Work Permit” (CDE B1-1) for the school attendance for each such minor. (EC 49162)

• Employers must retain a “Permit to Employ and Work” (CDE B1-4) for each such minor. (EC 49161)

• Work permits (CDE B1-4) must be retained for three years and be available for inspection by sanctioned authorities at all times. (EC 49164)

• A work permit (CDE B1-4) must be revoked whenever the issuing authority determines the employment is illegal or is impairing the health or education of the minor. (EC 49164)

• A day of rest from work is required in every seven days, and shall not exceed six days in seven. (LC 551, 552)

Minors under the age of 18 may not work in environments declared hazardous or dangerous for young workers, examples listed below: (LC 1294.1 and 1294.5, 29 CFR 570 Subpart E) 1. Explosive exposure 2. Motor vehicle driving/outside helper 3. Roofing 4. Logging and sawmilling 5. Power-driven woodworking machines 6. Radiation exposure 7. Power-driven hoists/forklifts 8. Power-driven metal forming, punching, and shearing

machines 9. Power saws and shears 10. Power-driving meat slicing/processing machines

HOURS OF WORK

16 & 17 Year Olds Must have completed 7th grade to work while school is in session. (EC 49112)

14 & 15 Year Olds Must have completed 7th grade to work while school is in session (EC 49112)

12 & 13 Year Olds Labor laws generally prohibit non-farm employment of children younger than 14. Special rules apply to agricultural work, domestic work, and the entertainment industry. (LC 1285–1312)

School In Session

4 hours per day on any schoolday (EC 49112; 49116; LC 1391) 8 hours on any non-schoolday or on any day preceding a non-schoolday. (EC 49112; LC 1391) 48 hours per week (LC 1391) WEE students & personal attendants may work more than 4 hours on a schoolday, but never more than 8. (EC 49116; LC 1391, 1392)

3 hours per schoolday outside of school hours (EC 49112, 49116; LC 1391) 8 hours on any non-schoolday No more than 18 hours per week (EC 49116; LC 1391) WEE students may work during school hours & up to 23 hours per week. (EC 49116; LC 1391)

2 hours per schoolday and a maximum of 4 hours per week. (EC 49112)

School Not In Session

8 hours per day (LC 1391, 1392) 48 hours per week (LC 1391)

8 hours per day (LC 1391, 1392) 40 hours per week (LC 1391)

8 hours per day (LC 1391, 1392) 40 hours per week (LC 1391)

Spread of Hours

5 a.m.–10 p.m. However, until 12:30 a.m. on any evening preceding a non-schoolday (LC 1391) WEE students, with permission, until 12:30 a.m. on any day (LC 1391.1) Messengers: 6 a.m.–9 p.m.

7 a.m.–7 p.m., except that from June 1 through Labor Day, until 9 p.m. (LC 1391)

7 a.m.–7 p.m., except that from June 1 through Labor Day, until 9 p.m. (LC 1391)

For more information about child labor laws, contact the U.S. Department of Labor at http://www.dol.gov/, and the State of California Department of Industrial Relations, Division of Labor Standards Enforcement at http://www.dir.ca.gov/DLSE/dlse.html.

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Frequently Asked Questions (FAQs) from International Students about the

Young Scholar Program (YSP) Thank you for your interest in the Young Scholar Program (YSP) at UC Davis. International students who participate in the program have additional requirements required to enter and stay in the United States while they participate in the program. The following Frequently Asked Questions (FAQs) may help you decide whether or not to participate. Q: What if I am an international student who is already studying inside the U.S.? A: If you are already in the United States, please contact Services for International Students and Scholars at ejtaylor@ucdavis.edu for more information on how to participate in the YSP. Q: What timeline should international students expect once accepted to the YSP? A: Because the time required for obtaining a U.S. visa varies based on the availability of visa appointments and because some visas require additional time to process, it is very important to get an I-20 as soon as possible. To allow adequate time, international students wishing to participate in the program should:

• ByApril15th:Accepttheirofferofadmissionandpaytherequireddeposit.• ByApril20th:OnceassignedaUniversityID,requestanI-20bysubmittingacopyofthepassportand

fundingrequired(instructionswillbeemailedtoyou).• Mid-May:OncetheI-20isreceived,thestudentandparentmustsigntheI-20acknowledgingthatthey

willfollowallF-1studentregulations,paytheSEVISI-901feeandmakeavisaappointment.Werecommendcheckingthecurrentwaittimeforobtainingavisaaswellasprepareforyourvisainterview.

• EnterU.S.withF-1visaMay20th-June18th:WaittomaketravelarrangementsuntilthevisahasbeenissuedORmakesurethetravelplanscanbeadjustedifthevisatakeslongerthanexpected.

Q: What items can be prepared while waiting to be accepted to the YSP? A: Minimum requirements for an I-20:

• Thestudentshouldhaveapassportthatisnotexpiringuntilatleast2017.• Arecentbankstatementnoolderthan3monthsoldshowingtheamountofatleasttheprogramexpense

of$6,200plusthecostofanyhealthinsurancepurchasedforthedurationoftheprogram.• Ifthefundsarenotinthestudent’sbankaccount,preparealetterfromtheownerofthebankaccount

statingthattheywillsponsorthecostoftheYSPforthestudent.

Q: Do international students have any additional costs to participation in the YSP? A: Yes. There is a $159 UC Davis fee, a SEVIS I-901 fee, a visa fee, and any additional costs associated with maintaining the required health insurance. Q: What are the health insurance requirements for international students participating in the YSP? A: International students are required to have health insurance that covers at minimum:

• Medicalbenefitsperaccidentorillnessofatleast:$100,000minimum• RepatriationofRemains:$25,000• ExpensesrelatedtoMedicalEvacuation:$50,000• Deductibleperaccidentorillnessnottoexceed$500• ContactEmilyTayloratejtaylor@ucdavis.eduforarecommendationaboutaninsuranceproviderif

necessary.

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Q: What should you expect during your visa interview? A: You will be expected to bring documentation and answer questions during your interview:

• Bringyourpassport,I-20signedbythestudentandtheparent,originalbankstatement(s),sponsorletter(s)ifapplicable,youracceptancenotificationintotheYoungScholarprogram,andanythingelseyouwereaskedtobringwhenfillingouttheI-160appointmentrequest.

• BepreparedtoanswerquestionsaboutwhyyouwanttoparticipateintheYoungScholarprogramatUCDavisandhowyouarepreparedfortheprogram.

• Bepreparedtoanswerquestionsabouthowyouwillfinancethisprogram(showfinancialdocuments).• Bepreparedtotalkaboutwhatyouwilldoaftertheprogramisfinishedandwhatwillbringyoubacktoyour

homecountrywhenyouarefinished.Moststudentstalkaboutreturningtoschool,family,investments(moneyinabankaccount),orproperty(yourhome)toshowstrongtiestoyourhomecountry.

Q: How early can an international student enter the U.S. to participate in the YSP? A: If the visa is issued in a timely manner, students can enter the U.S. up to 30 days prior to the program, but they are not eligible to check in to the program before the program start date. Q: Can parents accompany their international students to the U.S.? A: Yes, parents are welcome to accompany their students to the U.S. but will need their own visas. There are no provisions for parent participation or housing in the program other than dinner on the opening night. Q: How can parents obtain a visitor visa? A: Visitors who are not eligible for a visa waiver must apply for a B-2 visa. Q: Are there any additional requirements for international students once they arrive at UC Davis? A: Yes. International students must:

• AttendanorientationarrangedbytheYSP• ActivatetheirSEVISrecordbycompletinganonlinecheck-indiscussedduringthemandatoryorientation• MaintaintherequiredhealthinsuranceforthedurationoftheYSP• MaintaintheirSEVISstatusbyfullyparticipatingintheYSP

Q: Can an international student stay in the U.S. following the completion of the YSP? A: Yes, students who complete the program must check out of the program on July 30th, but are not required to leave the U.S. until the end of their 60 day grace period. Q: What if I have additional questions about international student requirements? A: Email your questions to ejtaylor@ucdavis.edu. Identify yourself as an applicant to the Young Scholar program.