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RISE Programs

Please choose the RISE program you wish to apply to below:

Applications open January 2019!

Student Information


Parent/Legal Guardian & Emergency Contact Information


Academic Information & Interests

Listed below is what you will need to bring:

RISE Program Check List

Six Changes of Clothing
Your dress should be casual. If you wish to swim, please bring your bathing suit or swim trunks. All attire MUST BE TASTEFUL: blue jeans, shorts, T-shirts, tennis shoes, sandals etc. The rule of thumb is to be comfortable, appropriate, and not revealing
Alarm Clock
We will be starting early each day, so if you have trouble waking up in the morning, BRING AN ALARM CLOCK!!!
Laundry Detergent
If you need to wear certain garments over again, the university has a laundry facility. You need to bring your own detergent. (Please bring money for washing machines)
Personal Toiletries
Please bring a body wash, a washcloth, towel, shampoo, toothbrush, toothpaste, deodorant, and other appropriate toiletries.
Money
All of the things you need to participate in the RISE Program workshops will be provided. There are other attractions at Cal Poly Pomona that might occupy your time. Therefore, you may want to bring extra money for your personal use

Restricted Items

(Note: Failure to comply with any of the below listed restrictions may result in expulsion)

NO PET OF ANY KIND!
No dogs, cats, hamsters, rats, lizards, frogs, turtles, snakes, or anything that breathes and is not human!
NO COOKING APPLIANCES OF ANY KIND!
No toasters, blender, hot plates, coffee pots, etc… NO Appliances!
NO FIREARMS, KNIVES OR EXPLOSIVE DEVICES OF ANY KIND!
Absolutely no B.B. Pellet guns, slingshots, spray paint, paint ball guns, hand guns, firecrackers, or explosive devices of any kind!
NO HOVERBOARDS!
NO ILLEGAL DRUGS! NO ALCOHOL! NO CIGARETTES!

Parental Release for RISE Program

Medical Authorization and Consent / Release Form
Pursuant to California Family Code §6910, I hereby authorize Cal Poly Pomona and the RISE Program their employees, agents and volunteers to provide routine health care and obtain medical treatment from an appropriate health care provider for minor or surgical treatment and/or medication as may be appropriate in what is deemed by them to be an urgent or emergency situation while attending the RISE Program.
I consent to any x-ray examination (or similar examination such as by CAT scan), anesthetic, medical or surgical diagnosis or treatment and hospital care to be rendered to the minor under the general or special supervision and under the advice of a physician and surgeon licensed under the provisions of the Medical Practice Act. I consent to an x-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care to be rendered to the minor by a dentist licensed under the provisions of the Dental Practice Act. I have not been given any guarantee or assurance as to the results of such treatment. I agree to accept financial responsibility for any and all costs for the foregoing.
Healthcare Provider Information

Medical Information

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Please press enter after each serious illness and/or operation, skip if does not apply

Please press enter after each known allergy, skip if does not apply

Check if applies

Check if applies

Check if applies

Check if applies

Parental Release for RISE Program

Visual/Audio Image and Quotations Release Form
I grant permission to Cal Poly Pomona, its employees and agents, to take and use visual/audio images and quotations of my minor child, RISE Program participant. Visual/audio images and quotations are any type of recording, including but not limited to photographs, digital images, drawings, renderings, voices, sounds, video recordings, audio clips or accompanying written descriptions. Cal Poly Pomona will not materially alter the original images. I agree that Cal Poly Pomona owns the images and all rights related to them. The images and quotations may be used in any manner or media without notifying me, such as university-sponsored websites, publications, promotions, broadcasts, advertisements, posters and theater slides, as well as for non-university uses. I waive any right to inspect or approve the finished images or any printed or electronic matter that may be used with them, or to be compensated for them.
I release the State of California; the Trustees of The California State University; Cal Poly Pomona; and their employees, officers, directors, volunteers and agents, including any firm authorized to publish, broadcast and/or distribute a finished product containing the images, from any claims, damages or liability which I may ever have in connection with the taking or use of the images or printed material used with the images.

RELEASE OF LIABILITY, PROMISE NOT TO SUE, ASSUMPTION OF RISK AND AGREEMENT TO PAY CLAIMS

Activity: Cal Poly Pomona RISE Program
Activity Date(s) and Time(s): July 22 - July 25August 5 - August 8
Activity Location(s): Cal Poly Pomona

In consideration for being allowed to participate in this Activity, on behalf of myself and my next of kin, heirs and representatives, I release from all liability and promise not to sue the State of California; the Trustees of The California State University; Cal Poly Pomona; and their employees, officers, directors, volunteers and agents (collectively “University”) and Cal Poly Pomona Foundation, Inc.; Cal Poly Pomona Associated Students Inc.; and their employees, officers, directors, volunteers and agents (collectively “Auxiliaries”) from any and all claims, including claims of the University’s and/or Auxiliaries’ negligence, resulting in any physical or psychological injury (including paralysis and death), illness, damages, or economic or emotional loss I may suffer because of my participation in this Activity, including travel to, from and during the Activity.

I am voluntarily participating in this Activity. I am aware of the risks associated with traveling to/from and participating in this Activity, which include but are not limited to physical or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability (including paralysis), economic or emotional loss, and/or death. I understand that these injuries or outcomes may arise from my own or other’s actions, inaction, or negligence; conditions related to travel; or the condition of the Activity location(s). Nonetheless, I assume all related risks, both known or unknown to me, of my participation in this Activity, including travel to, from and during the Activity.

I agree to hold the University and/or Auxiliaries harmless from any and all claims, including attorney’s fees or damage to my personal property that may occur as a result of my participation in this Activity, including travel to, from and during the Activity. If the University and/or Auxiliaries incur any of these types of expenses, I agree to reimburse the University and/or Auxiliaries. If I need medical treatment, I agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.


I am 18 years or older. I understand the legal consequences of signing this document, including (a) releasing the University and/or Auxiliaries from all liability, (b) promising not to sue the University and/or Auxiliaries, (c) and assuming all risks of participating in this Activity, including travel to, from and during the Activity.

I understand that this document is written to be as broad and inclusive as legally permitted by the State of California. I agree that if any portion is held invalid or unenforceable, I will continue to be bound by the remaining terms.

Type full name

If participant is under 18 years of age:

I am the parent or legal guardian of the Participant. I understand the legal consequences of signing this document, including (a) releasing the University and/or Auxiliaries from all liability on my and the Participant’s behalf, (b) promising not to sue on my and the Participant’s behalf, (c) and assuming all risks of the Participant’s participation in this Activity, including travel to, from and during the Activity. I allow Participant to participate in this Activity. I understand that I am responsible for the obligations and acts of Participant as described in this document. I agree to be bound by the terms of this document.

Type full name