Boston University School of Education Upward Bound Math Science

2 Silber Way Boston, Massachusetts 02215 T 617-353-3551 F 617-353-2395 www.bu.edu/ubms

April 25, 2018

Dear Parent/Guardian and Student:

Enclosed please find the Upward Bound Math Science 2018 Summer Forms Packet.

Please read the enclosed paperwork carefully and use the enclosed checklist. Most

other forms are due Monday, May 14. The student’s health care provider must sign the

immunization and health history records which is due Friday, June 1. Students will

be e-mailed a link to the online Residence Life Agreement which must be submitted

online.

Please note that students will not be allowed to move into the residence hall unless all of

these forms are fully completed and returned prior to the start of the summer program.

I strongly encourage the parents of first-time summer participants to attend the Upward

Bound and Upward Bound Math/Science Summer Open House on Saturday, June 9th

from 10:00 AM until Noon. The event will be held at the Boston University School of

Education, Two Silber Way, Room 130. A campus tour will be given and program staff

will be available for questions.

Finally, please review the enclosed information about mandatory placement testing

which will take place May 14th & 15th (make-up testing dates May 16th & 17th)

In closing, I look forward to a positive and productive summer. If you have any

questions on the enclosed information, please feel free to call our office at 617-353-3551

or e-mail me at acox@bu.edu.

Thank you.

Sincerely,

Allison Cox

Director

Upward Bound and Upward Bound Math Science 2018 Summer Forms Check List

The following forms are due Monday, May 14, 2018. Please use this check list below.

o Parent Consent, Waiver & Release o Roommate and Activity Selection Sheet o Summer Course Selection Sheet o Meal Benefit/Income Eligibility Form (Summer Food) o FitRec Waiver o Boston Afterschool and Beyond Summer Measurement Project Consent Form (Only students

who attend Boston Public Schools need to complete this form) o Immunization & Physical Form with Emergency Contact info, and Treatment Consent

The following forms are due June 1, 2018. Please use this check list below.

o Immunization & Health History Records (signed by a Doctor, Nurse or Medical Provider) The following form must be completed on line.

o Resident License Agreement (an electronic link to this online form will be e-mailed to students) For your records, also please review and keep the other documents enclosed.

o Summer Placement Testing Information o Summer Calendar o Summer Equipment List o Description of Classes and Activities o Summer Program Procedures and General Information o Summer Food Meal Pattern o Program Regulations

Forms can be submitted in person, faxed to 617-353-2395, or mailed to: Upward Bound Math Science Boston University, School of Education 2 Silber Way Boston, MA 02215 Please call our office at 617-353-3551 or e-mail Allison (acox@bu.edu) with any questions. Thank you.

Summer Placement Testing Upward Bound and Upward Bound Math Science

Currently Enrolled Students

Monday, May 14 - Writing and Math Placement

AND

Tuesday, May 15 - Reading Placement

Placement testing will take place in Sargent College, Room

101 located at 635 Commonwealth Avenue. Testing is from 3:45 p.m. to 6:00 p.m. each day

Can’t make it on the 14th and 15th?

Contact Lynn at lthach@bu.edu or 617-353-3551 Make-up dates are:

Writing and Math – Wednesday, May 16th

Reading – Thursday, May 17th

If a student scored post-high school on either the math or reading placement in summer 2016 or 2017, they are exempt from taking that placement test in summer 2018. There is no exemption for the writing placement. Lynn will email students to let them know if they are exempt.

Boston University School of Education Upward Bound Math Science

2 Silber Way Boston, Massachusetts 02215 T 617-353-3551 F 617-353-2395 www.bu.edu/ubms

UPWARD BOUND MATH SCIENCE AT BOSTON UNIVERSITY SUMMER 2018 PARENTAL CONSENT, WAIVER & RELEASE

I, _____________________________________ the parent/guardian of ____________________________________, give my consent of his/her participation in the Upward Bound Math Science Program being sponsored by the Boston University School of Education, the Boston Public Schools, and the Chelsea Public Schools. I understand my child will be living at Boston University, attending classes, conducting experiments in college science laboratories, visiting industry laboratories, conducting scientific field work, and participating in evening recreational activities at the university. I am also aware that my child will be participating in field trips that will include physically challenging outdoor activities at Prindle Pond in Charlton, MA and a Shakespeare performance in Lenox, MA. I have had the opportunity to read a description of summer classes and activities, summer program procedures and general information, and the summer program student regulations. I understand that the university has made no representation concerning the safety of the methods of travel to and from or the travel sites visited. I recognize that it is my responsibility to ask questions about any aspect of the program that has not been explained to my satisfaction.

I hereby agree, on behalf of myself and my child, to assume all of the risks in connection with my child's attendance at and participation in the Upward Bound Math Science Program, including travel, and I agree to release Boston University from any and all liabilities and claims whatsoever arising in connection with my child's attendance and participation, including travel, except insofar as such liabilities and claims arise out of Boston University's gross negligence or willful misconduct.

The term Boston University shall include the corporation named Trustees of Boston University and its successors, trustees, officers, agents, representatives, contractors and all persons for whose conduct the University is or could be legally responsible.

I agree that the laws of the Commonwealth of Massachusetts shall govern this Waiver & Release. I affirm that I have read and understood this document.

____________________________________ Signature of Parent or Guardian Date Printed Name Address State Zip code Daytime telephone #: Evening telephone #: I read and understood this Consent, Waiver, and Release and I agree to its terms on my own behalf. Signature of Student Date Student's printed name

Upward Bound and Upward Bound Math/Science at Boston University

2018 Summer Program

Roommate and Activity Selection Sheet

All students will live in Warren Towers, 700 Commonwealth Avenue. The residence hall has three towers. Males will live in one of the towers and females in another tower. All rooms are doubles. Every student will have a roommate. Make sure to speak to the person with whom you want to room so that both of you are selecting each other as roommates. Students who do not select a roommate will be assigned one. Please print. Your Last Name Your First Name Middle

Name of person you are selecting as roommate: Last First Middle

If you are not requesting a specific person as a roommate, please give us some information about the type of person you are and the type of person you would like for a roommate. Please include likes and dislikes, hobbies or special interests. Please use the space below for your response:

ACTIVITIES:

Students participate in activities on either Tuesday or Thursday evenings from 7 p.m. – 9 p.m. Please

rank your choices of recreational activities. You should mark your 1st, 2nd and 3rd choices.

There are no guarantees that you will get your top choices.

Arts and Crafts Soccer

Basketball Volleyball

Mock Trial Strength and Conditioning

Running _____________

Name: _________________________________________ Year of High School Graduation: ____________

High School: ____________________________________ High School ID #:_________________________

Boston University Upward Bound Math Science Course Selection Sheet You must have your school registrar or guidance counselor review and sign this form

Math Course Selection 1) Which classes best describes the math classes you will take in School Year 2018-2019 in your school?

Algebra 1 _____ Geometry _____ Algebra 2 _____ Pre-Calculus _____ Calculus _____

*AP Calculus _____ Other (describe): ___________________

*If you checked an AP class you must have your AP Teacher sign off on this sheet: AP Teacher Name________________________ Signature_________________________ Date___/___/___

2) Have you ever taken Pre-Calculus or Trigonometry: Yes No

Science Course Selection 1) Which classes best describes the science classes you will be take in School Year 2018-2019 in your school?

Biology _____ Chemistry _____ Physics _____ Anatomy _____

*AP Biology _____ *AP Chemistry _____ *AP Physics _____ Other (describe): ______________

*If you checked an AP class you must have your AP Teacher sign off on this sheet: AP Teacher Name________________________ Signature_________________________ Date___/___/___

2) Have you ever previously taken a High School Biology class: Yes No

Have you ever previously taken a High School Chemistry class: Yes No

Have you ever previously taken a High School Physics class: Yes No

School Official Verification - Required

A Guidance Counselor’s or Registrar’s signature below indicates that he/she has reviewed the above

information and that the student has accurately indicated which classes he/she will be taking in 2018-19 Name___________________ Title_______________ Signature______________________ Date___/___/____

Elective Preferences

1) Two days per week students take MCAS Prep, SAT Prep or Latin. Every student must take Latin one

summer. Rank your preferences (1, 2, and 3). Preferences will be considered, but are not a guarantee. Latin_____ MCAS Math_____ MCAS ELA_____

SAT Reading_____ SAT Math_____

2) Have you ever previously taken Latin in High School: Yes No

If you, or your school, have any questions, contact Lynn Thach at lthach@bu.edu or 617-353-3551.

INCOME ELIGIBILITY FORM FOR THE

SUMMER FOOD SERVICE PROGRAM

(For Use by Camps and Closed Enrolled Sites)

Please complete the following form using the instructions below. Sign the form and return it to:

[Name of Sponsor] __________Boston University Upward Bound and Upward Bound Math Science___________________

If you need help, call [phone number of Sponsor] _______617 353-3551 _________________________________

Follow these instructions, if your household gets SNAP, TAFDC, participates in Head Start, or is homeless:

Part 1: List participant’s name and a SNAP or TAFDC case number or indicate Head Start participation or homelessness.

Part 2: Skip this part.

Part 3: Skip this part.

Part 4: Sign the form. A Social Security Number is NOT required.

Part 5: Answer this question if you choose to.

If your household includes a FOSTER CHILD, use one application for the whole household and follow these

instructions. Please Note: Foster children are children formally placed in foster care by a State child welfare agency or a

court and the state must retain legal custody of the child. It does not apply to informal arrangements with relatives or others.

Part 1: Enter the child’s name.

Part 2: Please contact us at [617 353-3551]

Part 3: Complete this part if you are applying for other children in the household and you did not enter a SNAP or TAFDC

case number in Part 1 and did not indicate Head Start or homelessness.

Part 4: Sign the form. If Part 3 was completed, provide the last four digits of the signing adult’s Social Security Number.

Part 5: Answer this question if you choose to.

ALL OTHER HOUSEHOLDS, including WIC households, follow these instructions:

Part 1: List each participant’s name.

Part 2: Skip this part.

Part 3: Follow these instructions to report total household income from last month.

Column A–Name: List the first and last name of each person living in your household, related or not (such as

grandparents, other relatives, or friends who live with you). You must include yourself and all children living with

you. Attach another sheet of paper if you need to.

Column B–Gross income last month and how often it was received. Next to each person’s name, list each type

of income received last month, and how often it was received.

In Box 1, list the gross income each person earned from work. This is not the same as take-home pay. Gross

income is the amount earned before taxes and other deductions. The amount should be listed on your pay stub,

or your boss can tell you. Next to the amount, write how often the person got it (weekly, every other week, twice a

month, or monthly).

In box 2, list the amount each person got last month from welfare, child support, alimony.

In box 3, list Social Security, pensions, and retirement.

In box 4, list ALL OTHER INCOME SOURCES including Worker’s Compensation, unemployment, strike benefits,

Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), disability benefits, regular contributions from

people who do not live in your household. Report net income for self-owned business, farm, or rental income. Next

to the amount, write how often the person got it. If you are in the Military Housing Privatization Initiative do not

include this housing allowance.

Column C–Check if no income: If the person does not have any income, check the box.

Part 4: An adult household member must sign the form and include the last four digits of his or her Social Security Number,

or mark the box if he or she doesn’t have one.

Part 5: Answer this question if you choose to.

Privacy Act Statement: This explains how we will use the information you give us.

Non-discrimination Statement: This explains what to do if you believe you have been treated unfairly.

.

Part 1. Children enrolled in Camp or Closed Enrolled Sites.

Names (First, Middle Initial, Last)

SNAP or TAFDC case # (if any). Skip to Part 4 if you listed a case # or indicate Head Start or Homeless.

Part 2. Foster Child

Foster children are eligible for free and reduced-price meals regardless of household income. If a foster child lives with you, please contact UB/UBMS at 617 353-3551. Complete Part 3 if you are applying for other children in your household and you did not enter a SNAP or TAFDC case number or indicate Head Start or homelessness in Part 1.

Part 3. Total Household Gross Income—You must tell us how much and how often

A. Name (List everyone in household, including children)

B. Gross income and how often it was received Example: $100/monthly $100/twice a month $100/every other week $100/weekly C. Check

if NO income

1. Earnings from work before deductions

2. Welfare, child support, alimony

3. Social Security, pensions, retirement, 4. All Other Income

(Example) Jane Smith $200/weekly_____ $150/weekly_____ $100/monthly_____ $______/_______

$______/________ $______/_______ $______/________ $______/_______

$______/________ $______/_______ $______/________ $______/_______

$______/________ $______/_______ $______/________ $______/_______

$______/________ $______/_______ $______/________ $______/_______

$______/________ $______/_______ $______/________ $______/_______

$______/________ $______/_______ $______/________ $______/_______

$______/________ $______/_______ $______/________ $______/_______

Part 4. Signature and Social Security Number (Adult must sign)

An adult household member must sign this form. If Part 3 is completed, the adult signing the form must also list the last four digits of his or her Social Security Number or mark the “I do not have a Social Security Number” box. (See Privacy Act Statement on the back of this page.)

I certify that all information on this form is true and that all income is reported. I understand that this information is being given for the receipt of Federal funds. I understand that SFSP officials may verify the information. I understand that if I purposely give false information, the participant receiving meals may lose the meal benefits, and I may be prosecuted. Sign here: X______________________________Print name:_____________________________Date: ______________ Address:_______________________________________________________Phone Number:______________________ Last four digits of Social Security Number: __ __ __ __ I do not have a Social Security Number

Part 5. Participant’s ethnic and racial identities (optional)

Mark one ethnic identity: Mark one or more racial identities:

Hispanic or Latino Not Hispanic or Latino

Asian American Indian or Alaska Native

White Native Hawaiian or Other Pacific Islander

Black or African American

Don’t fill out this part. This is for official use only.

Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24, Monthly x 12 Total Income: ____________ Per: Week, Every 2 Weeks, Twice A Month, Month, Year Household size: ________ Categorical Eligibility: _____ Eligible _____ Not Eligible _____ Reason: ________________________________________________________________________________________ Determining Official’s Signature: _______________________________________________ Date: ______________ Confirming Official’s Signature: ________________________________________________ Date: ______________

March 2018

.

Privacy Act Statement: The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the social security number of the adult household member who signs the application. The social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP) or Temporary Assistance for Transitional Aid to Families with Dependent Children (TAFDC) Program case number for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the Program.

Non-discrimination Statement: In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. This institution is an equal opportunity provider.

USDA Form February 2016

ESE Form March 2018

Release, Acknowledgment of Risk, and Waiver of Liability for use of the Boston University Fitness and Recreation Center

MUST BE COMPLETED BY ALL PARTICIPANTS (Or by parent/legal guardian if participant is under 18 years of age)

In consideration of the opportunity to participate in classes, activities, and programs conducted by BU Upward Bound (“the

Program”), in the Boston University Fitness and Recreation Center and/or other University athletic facilities, and to use equipment

located therein,

☐ I, ________________, an ADULT, on behalf of myself and anyone claiming on behalf of me, or

(name of participant adult)

☐ I, ________________, the PARENT or LEGAL GUARDIAN of the child/children identified

(name of parent/guardian)

hereunder in the signature block, each a MINOR, on behalf of myself, my child/children, and anyone claiming on behalf of me or my

child/children, do hereby forever release, hold harmless, agree not to sue, and forever discharge Trustees of Boston University (the

“University”) and its departments, officers, directors, board members, representatives, agents, and employees from any and all claims,

demands, causes of action, judgment, damages, expenses and costs (including attorneys’ fees), including but not limited to claims of

negligence on account of personal injury, bodily injury, property damage, death or accident of any kind sustained by me and/or my

child that arises out of my or my child’s use of, presence in, or participation in activities conducted at the Fitness and Recreation

Center and other University athletic facilities, whether or not caused by the ordinary negligence of the University, which I may now or

hereafter have and which the above-named minor has or hereafter may acquire, either before or after reaching majority.

I understand, recognize, and acknowledge that certain activities conducted or taking place in the Fitness and Recreation Center and

other University athletic facilities are potentially hazardous and may involve the risk of accident, death, illness, physical or mental

injuries, and property damage. It is my responsibility to ask questions about any aspect of the Program activities that has not been

explained to my satisfaction. I hereby voluntarily assume any and all risks, including injury to person and property, related to my

participation and/or my child's participation in the Program. I further understand that, notwithstanding precautions taken by the

University, sports and fitness activities involve a risk of injury and/or death. I/we are voluntarily participating in these activities and

using equipment and machinery with knowledge of the dangers involved.

In signing this Release, Acknowledgment of Risk, and Waiver of Liability, I hereby acknowledge that I have read this entire

document, that I understand its terms, that I have signed it knowingly and voluntarily, and that I intend it to bind me and, as

applicable, my child/children and anyone claiming on behalf or me or my child/children.

I understand that I must abide by and follow all rules and policies outlined in the Membership Handbook. https://www.bu.edu/fitrec/about/forms-policies/

Event Dates: June 28, 2018 – July 24, 2018

Event Organizer: BU Upward Bound

Event Title: Volleyball and Basketball

(If participant is OVER 18 years of age)

Print Legal Name: _________________________________________________________________________

Signature: ____________________________________________ Date:_______________________

(If participant is under 18 years of age)

Print Your Child’s/Children’s Legal Name(s): ___________________________________________________

_________________________________________________________________________________________

Print Parent’s/Legal Guardian’s Name: _________________________________________________________

Signature of Parent/Legal Guardian: _______________________________ Date:______________________

Address: _______________________________________________________Phone: ____________________

Summer Measurement Project Consent Form – Please sign and return

Dear Parent/Guardian,

This program is taking part in a city-wide program evaluation project (the “Measurement Project”)

during Summer 2018. This Measurement Project, managed by Boston After School & Beyond, Inc.

(“BASB”), seeks to understand the quality of out-of-school and expanded learning time programming in

Greater Boston and how programs support student skill development and learning. Several research

organizations will help with the Measurement Project: National Institute on Out-of-School Time

(“NIOST”), the RAND Corporation, and ExpandED Schools (collectively, “Research Organizations”), and

the Boston Public Schools. All data collected will be kept confidential. By signing this Consent, I agree

to participate in the Measurement Project.

The following activities and information relates to Upward Bound or Upward Bound Math Science

students who agree to participate in Measurement Project:

Researchers and specialists will observe some summer classrooms and activities.

Assessments such as the Survey of Afterschool Youth Outcomes including Teacher, Staff, and Youth versions of the assessment and the Assessment of Afterschool Program Practices Tool will be used during programming. Students will be asked to fill out a survey called NIOST Survey on Afterschool Youth Outcomes (SAYO-Y). The SAYO-Y is a 10 minute paper or online survey which asks students questions about their program experiences, sense of competence, and future plans. Students will complete the survey once during the last week of the program. Participation in the survey is voluntary and may stop at any time without penalty. A study researcher will train the students on how to participate in the survey. Individual survey responses will not be shared with afterschool program staff, partner organizations, or any other organization or individual. Should you have any questions about this survey, use of these data, or questions about your rights, feel free to contact Dr. Georgia Hall at (781) 283-2530 or ghall@wellesley.edu or Nancy L. Marshall at nmarshall@wellesley.edu.

By signing this Consent, I authorize:

1. Boston University through its Upward Bound programs to share the following information about

me with Boston After School & Beyond, the Boston Public Schools (“BPS”), National Institute on

Out-of-School Time, the PEAR Institute, program funders or a network of program providers

(together, the “BASB Parties”) for purposes of analysis and for collaborative citywide evaluation:

name, date of birth, race, ethnicity, gender, school attended, current grade, home zip code;

to the extent such data is available to Upward Bound at Boston University: Boston Public Schools student identification number, State Assigned Student Identifiers, limited English proficiency status; and

program enrollment and attendance records, including hours attended per day.

2. The Boston Public Schools to share the following information about me with Boston Afterschool

and Beyond and NIOST:

2

school attended, race, gender, grade, age/date of birth, English language learner (ELL)

status, home zip code, school-year attendance (days present, days tardy, rate), test

scores, State Assigned Student Identifier (SASID) and Boston Public School ID.

In public reporting of research findings, only group data will be reported. At no time will a public report

identify an individual student in any way. The only exception to confidentiality will be in the case of any

information disclosed that indicates a child is in any danger. Should that occur, protocols for such

disclosure are in place for protection of participants.

I give Boston University permission to collect the student state and school ID number from my child’s

school to be used for access to student records. Boston University will provide services to my child

regardless of parent/guardian consent for student records.

Please complete, sign, and return:

STUDENT CONSENT: I hereby permit Boston University to release the aforementioned information

about me and my participation in the Upward Bound programs to the BASB Parties.

____________________________________ ____________________________________

Student’s Signature Date

PARENT/GUARDIAN CONSENT: I, __________________, the parent/guardian of

_______________________ do hereby permit Boston University to release the aforementioned

information about my child and his/her participation in Upward Bound to the BASB Parties.

____________________________________ ____________________________________

Parent’s Signature Date

Photo/Video Release

Boston Public Schools, Boston After School & Beyond, and/or their partners and agents may videotape or take

pictures of your child’s participation in the Summer Measurement Project using video and/or digital photography.

These images may be taken before, during, or after the summer programming. These images may be used for the

purpose of sharing your child’s participation, and perspectives associated with your child’s participation, to a public

audience. Images may be published, posted, or played through a variety of communication channels, including but

not limited to print, television, and/or online. Please sign below to agree.

Parent/Guardian Signature: ___________________________________ Date: ___________________

Student Signature: ___________________________________ Date: ___________________

Revised February 2018 Page 1

PLEASE FAX OR MAIL REQUIRED INFORMATION TO YOUR SUMMER PROGRAM

IMMUNIZATION AND PHYSICAL FORM

Date Entering / Month Year

Student Information

Student Name Last First Middle

Date of Birth Boston University ID Number Month Day Year

Summer Program Active Email Address

Emergency Contact Alternate Emergency Contact

Name and relationship of contact Name and relationship of contact

Street Address Street Address

City State Zip City State Zip

Contact Phone Number Contact Phone Number

For comprehensive information about Student Health Services including hours and directions, please visit our website at:

www.bu.edu/shs Consents and acknowledgements

I hereby authorize the clinical staff at Boston University Student Health Services to examine and treat me during my enrollment at Boston University.

Initial

I consent to authorize emergency and non-emergency medical care to be provided to my child in the event of a health problem, emergency or injury occurring during my child’s attendance at, or participation in, the Summer Program. I give my consent and authorization to the Program Director or his/her designee to use his/her judgment in seeking medical care for my child. I understand that an attempt will be made to contact me in the event that emergency medical care is needed.

Initial

I understand that there is a copay to see a provider at Boston University Student Health Services for each appointment. I understand that I am responsible for miscellaneous charges including, but not limited to, lab tests, allergy injections, immunizations, and some supplies. I understand that I am responsible for all health care charges outside of Student Health Services except that which is covered by my health insurance.

Initial

I understand that some costs outside of Student Health Services may not be covered by my medical insurance. Initial

I understand that Student Health Services is a unit inclusive of medical, mental health, nutrition, sports medicine, and alcohol and other drug services. I understand that the providers within this organization may discuss my care within the unit to allow for effective care delivery and care management.

Initial

I understand that some services provided are limited by staff and space availability. While we may endeavor to serve all students eligible for care, there may be circumstances when referral to outside providers in the community is necessary.

Initial

The information on this form is for the use of Student Health Services and will not be released to a third party without your consent, except as necessary to fulfill the responsibilities of Student Health Services or as required by law.

Initial

Student Signature Date

Parent/guardian signature Parent/guardian name (please print) Date Relationship to Student

(Must be signed by a parent or guardian if student is under 18 years of age)

Revised February 2018 Page 2

Last Name Date of birth BU ID Number

Required Immunization Record Must be signed by MD/NP/PA and must include MM/DD/YYYY

Must be completed PRIOR to arrival at Boston University

Vaccines Dates Given Massachusetts State Requirements

MMR

#1 / / #2 / / MM DD YYYY MM DD YYYY

• 2 doses of MMR

• Minimum of 4 weeks between doses

OR

• 2 doses of each individual component (2 measles, 2 mumps, and 2 rubella)

• Minimum of 4 weeks between doses

OR

• Positive titers

The first dose given MUST be received after your 1st birthday

OR Oldest Newest

Individual Vaccines: Measles Mumps Rubella

Measles #1 / / #2 / /

MM DD YYYY MM DD YYYY Oldest Newest

Mumps #1 / / #2 / /

MM DD YYYY MM DD YYYY Oldest Newest

Rubella #1 / / #2 / /

MM DD YYYY MM DD YYYY Oldest Newest

OR

Positive Titers

Measles Titer Date: / / MM DD YYYY

Mumps Titer Date: / / MM DD YYYY

Rubella Titer Date: / / MM DD YYYY

Tdap

/ / (Td shot is NOT acceptable, must be Tdap) MM DD YYYY

Tdap (Tetanus, Diphtheria & Pertussis) is the only acceptable form of Tetanus

shot. This must be within 10 years.

Hepatitis B

#1 / / #2 / / #3 / / MM DD YYYY MM DD YYYY MM DD YYYY

Oldest Newest

Completed 3 part series

OR

Positive titer Titer Hepatitis B Positive Titer Date / / MM DD YYYY

Varicella

#1 / / #2 / / MM DD YYYY MM DD YYYY

2 doses of varicella vaccine

OR Oldest Newest

Positive titer Titer Varicella Positive Titer Date / / __

OR MM DD YYYY

History of disease must be verified by a medical provider with the MM/DD/YYYY Disease Date of Disease / /

MM DD YYYY

Clinician name MD/NP/PA (please print) Signature Date

Revised February 2018 Page 3

OR

Last Name Date of birth BU ID Number

Meningitis Record

One dose within 5 years for all students living on campus required or a completed waiver.

Meningitis Vaccination: Menactra Menomune / / _ _ / /

MM DD YYYY MM DD YYYY

MENINGITIS WAIVER

Meningococcal Waiver is ONLY if you plan on waiving the requirement for the Meningococcal Vaccine. If you have received the vaccine, please ignore this waiver.

Waiver for Meningococcal Vaccination Requirement

I have received and reviewed the Meningococcal Information Form provided on the risks of meningococcal disease and the risks & benefits of meningococcal vaccine (available at http://www.bu.edu/shs/immunizations) Check below:

After reviewing the materials above on the dangers of meningococcal disease, I choose to waive receipt of the meningococcal vaccine.

Student Signature: Date: (Parent/Guardian signature if student is under 18 years old)

Where can I get more information?

• Your healthcare provider • The Massachusetts Department of Public Health, Division of Epidemiology and

Immunization at (617) 983-6800 or www.mass.gov/dph • Your local health department (listed in the phone book under government)

Clinician name MD/NP/PA (please print) Signature Date

Revised February 2018 Page 4

1. 2. 3.

Are you an international student? To the best of your knowledge, have you had close contact with anyone who was sick with tuberculosis? Were you born in or have you travelled for extended periods of time (more than 1 month) to one of the high risk countries found here: http://www.bu.edu/shs/immunizations Have you completed 6-9 months of medication to prevent active tuberculosis?

YES YES

NO NO

YES NO

4. YES NO

(i.e. isoniazid)

• If you answered YES to any questions you must provide proof of a recent tuberculosis test administered within last year:

Last Name Date of birth BU ID Number

Tuberculosis Record REQUIRED FOR ALL INTERNATIONAL STUDENTS AND DOMESTIC STUDENTS

COMPLETED BY STUDENT AND SIGNED BY HEALTH CARE PROVIDER (MD/NP/PA)

Part A. Tuberculosis

1. Have you had a positive tuberculosis skin test in the past? YES (complete below) NO (skip to Part B)

Only In The Case Of A Positive Test, Complete The Following: Positive Skin Test: Plant Date / / Plant Read / / Result in MM: Blood QuantiFERON Gold Test: / / _ Result: Positive Negative

Have you ever had a BCG Vaccine? Yes / No If Yes: what was the date of the vaccine? / /

Because the Tuberculosis Skin Test is Positive, you will need to complete the following evaluation/treatment:

Chest X-Ray Date: / /

Result: □ Normal □ Abnormal (describe)

Clinical Evaluation Date: / / (Must be within 1 year of matriculation)

Part B. Tuberculosis

Tuberculosis Skin Test (Must be within the past year)

Plant Date / /

Read Date (within 48-72 hours of plant) / /

MM

QuantiFERON Gold Test Date / /

Result: Positive Negative

Clinician name MD/NP/PA (please print) Signature Date

RETURN TO UB/UBMS by June 1, 2018

UB and UBMS Health History Form - 2018

Student Name:__________________________

Date of Birth:_____/_____/_________

List any significant current and past medical, surgical, or mental health conditions including hospitalizations. Use additional pages if needed.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

List any ongoing medications or treatments including dosages/directions & describe what condition it is treating. Use additional pages if needed.

Medication Name Dosage/Directions Condition addressed by medication

List Any Allergies: Use additional pages if needed.

Food Allergies & Restrictions Medical Allergies Environmental Allergies

List any pertinent family medical history:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Date of most recent physical exam _____/_____/_____ (requested, but not mandatory). Has the student been evaluated by a clinician (MD/NP/RN) to be in good physical health and able to participate in academic activities and recreational sports activities, if they choose to do so:

YES NO If NO, please explain below:

__________________________________________________________________________________________________________________________________________ Parent/Guardian Name: __________________________________________________ Parent/Guardian Signature: __________________________________________ Date:_____________

UPWARD BOUND MATH SCIENCE at BOSTON UNIVERSITY PROGRAM DATES, June 24 to August 3, 2018

SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY June 24

Students

Move-In

2:00 – 4:00 PM

Warren Towers

5:00-6:00 Dinner

6:00 – 9:00 Meeting

25

Morning Student

Orientation

Terrier Cards

Books and

Schedules

Team Meeting

26

PRINDLE POND

OUTDOOR

CENTER

BOARD BUS 8:30 AM

27

PRINDLE POND

OUTDOOR

CENTER

BUSES RETURN TO BU 4:00 PM

Prepare for Classes

28

Classes Begin

Activities or Free

Time

29

Classes

Students go home

2:00-5:00 PM

July 1

Students return

to campus

6:00-11:00 PM.

2

Classes

Team Projects

3

Classes

Students return

home for 4th of July

Holiday

2:00-5:00 PM

4

HOLIDAY

PROGRAM

CLOSED

5

Students return to

campus by 7:30

a.m. for first

period class

Classes

Activities or Free

Time

6

Classes

Students go home

2:00-5:00 PM

8

Students return

to campus

6:00-11:00 PM

9

Classes

Team Projects

10

Classes

Activities or Free

Time

11

UBMS Labs

Team Projects

12

Classes

Activities or Free Time

13 Classes

Mid-Term

Grades Due

Students go home

2:00-5:00 PM

15

Students return

to campus

6:00-11:00 PM

16

Classes

Team Projects

17

Classes

Activities or Free

Time

18

UBMS Labs

Team Projects

19

Classes

Activities or Free Time

20

Classes

Students go home

2:00-5:00 PM

22

Students return

to campus

6:00-11:00 PM

Multicultural Pot

Luck and Talent Show 7-10 p.m.

(*tentative date*)

23

Classes

Team Projects

24

Classes

Mock Trial

7-9 p.m.

Activities or Free

Time

25

UBMS Labs

Team Projects

26

Shakespeare

Trip

Lenox, MA 10:00am – 8:00 pm

27

Classes

Students go home

2:00-5:00 PM

29

Students return

to campus

6:00-11:00 PM

30

Final Exams

Team Projects

31

Final Exams

Book Return

All Program

Evening Sporting

August 1

Project Presentations

Awards Rehearsal

Special Evening Activities

2

Final Grades Due

Field Day

Awards Ceremony 6:00-9:00

Dance

3

Students

and Staff

Move-out

9 am - 10 am

Boston University Upward Bound and Upward Bound Math Science

LIST OF ITEMS TO BRING

Dormitory: Warren Towers, 700 Commonwealth Avenue

Move In Date: Sunday, June 24, 2018

Move In Time: 2:00 PM - 4:00 PM

Items You Will Need at Boston University:

Very Important Items Optional Items Photo ID (you will need this to get your BU Terrier Card)

Sheets & Blanket (twin size)

Pillow & Pillowcase

Towel

Toiletries Kit (soap, shampoo, toothbrush & paste, comb or brush)

Summer Clothes & Jacket

FAN (Make sure to bring a fan. The rooms get hot)

Headphones (for rising seniors taking SAT Prep)

Small Refrigerator (max. 4 cubic

feet)

Computer or Laptop

Radio

Hair Dryer

Bicycle

Small Television

Cell Phone

You May NOT Bring Cooking appliances (microwave ovens, coffee pots, hot plates, etc.)

Air conditioners

Anything with an open flame (candles, incense, etc.)

Prindle Pond Outdoor Center Overnight Trip (June 26 & 27)

Very Important Items Optional Items

Sleeping Bag or 2 sheets & blanket and pillow

Water Bottle

Mosquito Repellent

Sun Screen

Raincoat and Hat

Sneakers or non-leather soled shoes

Jacket or Sweater & Long Pants

Toiletries Kit (soap, shampoo, toothbrush & paste, comb or brush)

Bath Towel

Pajamas

2-3 changes of clothes including 3 pairs of socks/underwear

Swim Trunks or Bathing Suit

(swimming might be an option)

Flashlight

Sunglasses

Upward Bound Math Science at Boston University Description of Classes and Activities

June 24 to August 3, 2018

Upward Bound Math Science at Boston University is a higher education opportunity program funded by a TRIO grant from the United States Department of Education and by Boston University. Fifty (50) students participate in the program from June 24 to August 3. Students attend one of four target high schools or live in one of five target neighborhoods. The target high schools are Boston Green Academy, Charlestown High, Chelsea High, and Josiah Quincy Upper School. The target neighborhoods are Chelsea, Dorchester, East Boston, Mattapan, and Roxbury. This will be the program’s eleventh summer at Boston University. Our Math Science Program joins our traditional Upward Bound program, which will serve 86 students and operate for its twenty-ninth summer at Boston University. PROGRAM DESCRIPTION: The main goal of the program is to enrich the academic skills of our students in order to better prepare them for college. We believe in a holistic approach to education, in other words, in focusing on all aspects of the students' development. Thus, the summer program activities are designed to promote intellectual development as well as emotional, moral, and social development. All students attend 16 hours of instruction each week: 4 hours - Literature and Writing 4 hours - Mathematics 4 hours - Science 2 hours - Of either Latin, MCAS Preparation, or SAT Preparation 2 hours - Computer Science In addition, all students participate in the following activities: *Science Wednesdays – 7 hours per week.

*Field trips and group projects, which promote cultural and academic enrichment, cooperation and group spirit. *Study hall and discussion classes with tutors - 6 hours per week.

*Individual tutor/student conference - 0.5 hours per week. *Personal and academic counseling as appropriate. *Sports and recreational activities - 2 hours per week. Six undergraduate students participate as full-time tutors. They provide tutoring in all subject areas and assistance in developing students’ study, time management, and note taking skills. Additionally, they serve as team leaders, peer counselors, and positive role models for Upward Bound Math Science students. Upward Bound Math Science students reside in B.U. dormitories during the week and return home for the weekends. An 11 p.m. curfew with a midnight in your room/lights out policy is enforced. Most of our tutors and a dormitory supervisor live in the dormitories in addition to a Boston University residence assistant on each floor. Our tutors and dormitory supervisor enforce the lights out policy, assist students in waking up on time in the morning, and promote a positive home environment in the residence hall. The director of Residence Life, the resident assistants (RA’s), and the residential safety staff will enforce all Boston University rules and regulations.

ACADEMIC PROGRAM: Major Courses (meet four days a week). Literature & Writing: Students take four hours of literature & writing class per week. The Stanford 9 Reading Test and a writing test are administered as a pre-test to all students to assess vocabulary, reading comprehension and writing levels. Students are placed into courses based on the results of the tests. Grade level does not determine student placement. All students read Macbeth by William Shakespeare. To reinforce their reading of the play, students attend a live performance of the play presented by Shakespeare & Company in Lenox, Massachusetts. In addition, students read additional works which will be selected by UBMS teachers and administrators. Instruction and homework focus on comprehension of plot, character development, vocabulary, treatment of theme, critical analysis, and acquisition of a basic understanding of the poetics and dramatic structure. Grammar review is also an integral part of instruction along with an emphasis on style and point of view. Students work closely with writing teachers to discuss their papers and works in progress. Students receive written and oral critiques from their teachers. Science: Students take four hours per week. Four levels of science are offered: biology, anatomy and physiology, chemistry, and physics. Course content is designed to give students a preview of their science course during the 2018-19 school year. There is a weekly laboratory component for each level offered. Mathematics: All students take four hours of math per week. Five levels are offered: advanced algebra I, geometry, algebra II, pre-calculus, and calculus. Course content is designed to give students a preview of their math course during the 2018-19 school year. Minor Courses (meet two days a week): Computer Science: All students will take a computer science course, which is designed to introduce some component of computer programming. Each student takes one of the following courses: SAT Preparation: Two sections are offered: SAT math or critical reading. Students take two hours of one section per week. Students will review test taking strategies, complete practice test sections, and utilize online practice materials. Latin: Students learn about the Roman Civilization and the basics of Latin. The course also introduces students to the impact Latin words have on the Romance languages and on English. MCAS Preparation: Two sections are offered: MCAS mathematics preparation and MCAS English language arts preparation. Students take either two hours of English language arts preparation or two hours of mathematics preparation per week. Students also practice on mini-tests.

Course Grading: In all courses students will complete homework, take quizzes, a mid-term exam and a final. Two grade and written reports are issued to students, one after the third week, and one at the end of the program. Science Wednesdays & Senior Internships: Students will participate in hands-on and exploratory science activities, as well as opportunities to work in research labs and to learn about careers in science. This model provides integration with academic researchers at Boston University and offers expanded opportunities for program participants to prepare in greater depth for study in the STEM fields (science, technology, engineering and math) at the post-secondary level. Some rising 12th grade students will have the opportunity to apply to do a research internship in lieu of a Science Wednesday Lab. Spaces are limited for research internships. Details to apply for internships will be sent to qualifying students. TUTORING TEAMS: Six undergraduate students work as full-time tutor/counselors. The tutors receive a week of training before the program starts. The training focuses on the various facets of their role and is led by the program's director, the academic & college counselor, the academic resource counselor, and the dormitory supervisor. In addition, during the program, the tutors have regularly scheduled meetings with the teachers and administrative staff. Each tutor is assigned a team of 8-9 students for the six-weeks of the program. Each team is multi-ethnic, includes students at each grade level and, to the extent possible, an equal distribution of males and females. The tutor maintains close contact with each member of his/her team through the following activities:

*Four hours of weekly tutor team meetings to support students work on Science Wednesdays & Team Projects

*Weekly individual student/tutor conferences *Six hours of study hall *Recreational activities *Field trip participation The tutors play a pivotal role in the program. They provide the students with academic assistance, personal and emotional support, and first-hand information about college life. They often serve as liaisons between the students and the teachers. Additionally, tutors supervise students during team meetings and assist in students’ preparation of the team projects that are presented at the end of the summer. Tutors evaluate their students after the first three weeks and at the end of the program. Students also write evaluations of their tutors. STUDY HALL: Study hall takes place on Mondays, Tuesdays and Thursdays from 3:00 PM to 5:00 PM. All students are required to attend study hall. Each Tutor Team will be assigned to a classroom during study hall time. All Tutors are present at Study Hall each day and each Teacher attends Study Hall one day per week to assist students with work and to answer questions. ADDITIONAL ACTIVITIES: Students participate in the following activities designed to help promote team spirit and cooperation, open-minded attitudes toward the multi-ethnic student population of the program, and a social consciousness in the context of the Boston community: Prindle Pond Outdoor Education Center over-night program at Prindle Pond Outdoor Education Center in Charlton, MA: This field trip will be held from Tuesday, June 26 to Wednesday, June 27. Students and tutors will spend the night in the cabins of the Prindle Pond

Outdoor Education Center. The purpose of this trip is to build ties within the Upward Bound and Upward Bound Math Science community, to build effective team-work, and to improve motivation, and self-confidence. Activities will include but are not limited to low-ropes course activities, team-building games, and possible access to swimming and a camp fire. Sports and Recreational Activities: Tuesday and Thursday evenings from 7 p.m. to 9 p.m. are reserved for sports and recreational activities. Students sign-up for activities, which will meet on either Tuesday or Thursday. Activities include: soccer, basketball, volleyball, strength & conditioning, mock trial, and arts & crafts. The academic resource counselor and the tutors supervise the activities.

Upward Bound Math Science at Boston University

Summer Program Procedures and General Information

Welcome to the 2018 summer program, our eleventh summer at Boston University! The

six-week summer residential program will run from the afternoon of Sunday, June 24 through the

morning of Friday, August 3. This information will familiarize you with the schedule and general

procedures for the program. Classes and activities are described separately.

Check-in: All students will move in on Sunday, June 24, with check-in occurring between 2 p.m.

and 4 p.m. in Warren Towers, 700 Commonwealth Ave. Female students and males students

will be assigned to separate towers. All bedrooms are doubles. Students will be notified of room

assignments at check-in. Students will also be issued temporary identification cards, which they

must use to enter and exit the dormitory on Sunday and Monday, until they get their Terrier Cards.

Terrier Cards (I.D. Cards): Terrier Cards serve as students’ identification cards. Students

should carry their Terrier Cards with them at all times, as Terrier Cards need to be presented by

students when they enter Towers, the dining hall, libraries, athletic centers, and other facilities at

Boston University. Terrier Cards will be issued between 1:30 p.m. and 4:30 p.m. on Monday,

June 25. Students will need to return their temporary identification cards at this time.

Students should also bring photo identification with them to the Terrier Card Office. If

students participated in a prior summer program, they should also bring their old Terrier Cards.

Students, please note! The University charges up to $125 for lost keys and $40 for Terrier Card

replacements. They do not make any exceptions. You cannot eat in the dining room or enter your

on-campus residence without your Terrier Card so please do not to lose it.

Meals: All meals must be eaten in the Warren Towers, 700 Commonwealth Ave. When

entering the dining room students must present their Terrier Cards to the cashier. Students will be

provided with fourteen meals a week. This plan allows for breakfast, lunch, and dinner from

Mondays through Thursdays, and breakfast and lunch on Fridays. Students should have dinner at

home on Fridays and will not be allowed to use their 14-meal plan on weekends.

Dining Service Hours for Upward Bound Math Science students:

Breakfast 7:30 a.m. - 8:20 a.m.

Lunch 11:30 a.m. - 12:20 p.m.

Dinner 5:00 p.m. - 5:50 p.m.

Lastly, Boston University Upward Bound Math Science participates in the U.S.D.A. Summer Food

Service Program. Upward Bound Math Science’s involvement in the U.S.D.A. Summer Food

Service Program requires our staff to monitor all students’ dietary intakes to insure that they match

U.S.D.A. meal pattern guidelines. Because of this mandate, all students must present their meals

to the Upward Bound Math Science tutor on dining room duty prior to the students’ sitting

down to eat. When choosing food in the dining room, students should make sure their choices

comply with the required meal patterns, a copy of which is enclosed.

Curfew: Everyone must be inside Warren Towers and on an assigned program floor no later than

11 p.m. sharp Sunday through Thursday. During free time, if a student will be outside the

residence hall after 7 p.m. they must sign the log next to the security assistant at the front entrance

of the dormitory. Therefore, if a student leaves the building prior to 7 p.m., they must return by 7

p.m. to sign back out. The log is available from 7 p.m. until curfew. Students must clearly print

where they plan to be, for example, B.U. Beach, or CVS. For safety reasons, no one is allowed to

write "I'm out." and certain areas on campus may be restricted. Curfew is strictly enforced for all

high school summer programs at Boston University.

Lights-out: Everyone must be inside his/her designated bedroom with lights out no later than

midnight. Live-in tutors will take attendance on the dormitory floors at 11:00pm and check that

students are in their designated rooms by midnight. Students must comply with tutors taking

attendance during curfew and lights-out.

Lights-out Rules:

1. No student is allowed to sleep in a room other than the one assigned to him/her.

2. Students must be inside their assigned bedrooms no later than midnight.

3. Lights should be off by 12:00 midnight.

4. Voices should not be audible outside the bedrooms from midnight to 6:30 a.m.

5. Radios, televisions, video games or other like devices must be off from midnight to 7:00 a.m.

Conduct: Students are expected to follow the rules and regulations of Upward Bound Math

Science and Boston University. Program expectations can be summarized by the following three

statements:

1. Students are expected to attend, be on time for, and be active participants in every class and

activity on their schedule.

2. Students are expected to complete their homework and any other given assignment on time.

3. Students are expected to contribute to the Upward Bound Math Science and Boston University

community with thoughtful and positive attitudes and respect towards all.

In addition to the above stated expectations, please refer to the enclosed Upward Bound

Math Science student regulations and the Boston University Office of Residence Life Book (which

is available online at http://www.bu.edu/lifebook/). A review of these rules will be conducted by

Upward Bound Math Science and Residence Life staff during an evening meeting on Sunday, June

24. Students who fail to comply with the University or program regulations will be subject to

disciplinary action by the University and/or the Upward Bound Math Science staff. Disciplinary

action may result in a range of sanctions including, but not limited to early curfew time, restriction

from participation in field trips and activities, suspension from the program, dismissal from the

program and/or the on-campus residence.

Leaving campus: The Upward Bound Math Science program has an intensive and full schedule

from Monday to Friday. Please see the enclosed program description. From June 24 to August 3,

students should not make any other commitments from Sunday evenings to Friday afternoons.

Daytime Appointments: Whenever possible, students should schedule appointments

outside of Upward Bound Math Science program dates and hours. Late on a Friday afternoon is

generally the best time. In the event that a student must attend an appointment during the program,

permission to leave campus will only be granted with written parental consent. Allison Cox, the

program director, should receive a note or email (acox@bu.edu) from the student's parent or

guardian at least 48 hours prior to the expected departure.

Overnights: Permission to leave campus over-night will only be granted with written and

verbal parental consent. Allison Cox, the program director, should receive a note or email

(acox@bu.edu) from the student's parent or guardian at least 48 hours prior to the expected

departure. After the note or email is received, Allison will call the parent or guardian to confirm.

Permission to come in after curfew (11:00 P.M.) cannot be granted, these requests will be

treated as overnight off campus. Students will be expected to return to campus before their first

scheduled class or activity the next morning.

Sick Policy: Students who miss program classes or activities as result of illness will need to be

taken home by a family member for treatment with their family’s healthcare provider. Ill students

will not be allowed to take public transportation home. Students who are well enough to go to

class, but need non-emergency medical care may be taken by program staff to Student Health

Services, located at 881 Commonwealth Avenue. In either circumstance, program staff will

contact the students’ parents or guardians.

Additionally, and most importantly, any student missing more than two days of classes

due to illness during the summer may be subject to commuting to campus for the duration of the

summer.

Guest Policy: Immediate family and program alumni are authorized visitors on campus.

Immediate family may sign into the residence hall with the approval of Upward Bound staff.

Otherwise, students are not allowed to have guests on campus.

Smoking Policy: Students are not allowed to smoke unless they are over 18 years of age.

Students may only smoke in designated areas. Smoking is prohibited in all University student

residences and dining rooms.

Prindle Pond Over-night Trip: All students are required to participate in the Upward Bound

Math Science over-night trip to the Prindle Pond Outdoor Education Center located in Charlton,

MA. A list of what to bring and a Parental Consent sheet are enclosed. When the students move

into the dormitory, they should bring anything needed for this trip. The trip will take place from

Tuesday, June 26 to Wednesday, June 27. Any student who cannot participate due to a medical

condition must go home Monday (June 25) evening and return to the dorm Wednesday (June 27)

evening. Students will only be exempt with parental permission.

Schedule: Students will have access to their rooms from 6 p.m. on Sundays to 5 p.m. on Fridays.

Students must return home for the weekends, and no student should be in Towers after 5 p.m. on

Fridays or before 6 p.m. on Sundays.

Stipends: Students will be paid a stipend at the end of the summer program after satisfactorily

completing the program and checking out of their dorms. Students will receive a check in the

amount of $90. The U.S. Department of Education determines this amount.

Open House: Please join us for a Boston University tour and visit of the summer on-campus

residence, dining room, and classrooms. We will meet on Saturday, June 9, at 10 a.m. in the

School of Education (SED) located at Two Silber Way, room 130.

Awards Ceremony and Reception: Every parent and guardian should feel proud of his/her child

for completing the Upward Bound Math Science Summer Program. We ask you please plan to

attend the Summer Awards Ceremony on Thursday, August 2nd from 6:30 p.m.-8:30 p.m.

Check-out: Students must move out of the dormitory between 9:00 a.m. and 10:00 a.m. on

Friday, August 3rd. Keys must be turned in during check out to avoid being charged for a

replacement. No final stipend checks will be issued until students complete this process.

Should you have any questions or concerns, do not hesitate to call us at

(617) 353-3551 or e-mail Allison at acox@bu.edu. If you need additional copies of the enclosed

summer forms, you can download them from our website at http://www.bu.edu/ubms/forms

Summer Food Service Program Meal Patterns

Breakfast Lunch or Supper

Snack1 (Choose two of the four)

Milk Milk, fluid

1 cup (8 fl. oz.)2

1 cup (8 fl. oz.)3

1 cup (8 fl. oz.)2

Vegetables and/or Fruits Vegetable(s) and/or fruit(s), or Full-strength vegetable or fruit juice or an equivalent quantity of any combination of vegetables(s), fruit(s), and juice

½ cup ½ cup (4 fl. oz.)

¾ cup total4

¾ cup ¾ cup (6 fl. oz.)

Grains and Breads5 Bread or Cornbread, biscuits, rolls, muffins, etc. or Cold dry cereal or Cooked pasta or noodle product or Cooked cereal or cereal grains or an equivalent quantity of any combination of grains/breads

1 slice 1 serving ¾ cup or 1 oz.6 ½ cup ½ cup

1 slice 1 serving ½ cup ½ cup

1 slice 1 serving ¾ cup or 1 oz.6 ½ cup ½ cup

Meat and Meat Alternates Lean meat or poultry or fish or alternate protein product 7

or Cheese or Eggs or Cooked dry beans or peas or Peanut butter or soy nut butter or other nut or seed butters or Peanuts or soy nuts or tree nuts or seeds or Yogurt, plain or sweetened and flavored or An equivalent quantity of any combination of the above meat/meat alternates

(Optional) 1 oz. 1 oz. ½ large egg ¼ cup 2 tbsp.

1 oz.

4 oz. or ½ cup

2 oz. 2 oz. 1 large egg ½ cup 4 tbsp. 1 oz.= 50%8

8 oz. or 1 cup

1 oz. 1 oz. ½ large egg ¼ cup 2 tbsp.

1 oz.

4 oz. or ½ cup

For the purpose of this table, a cup means a standard measuring cup. Indicated endnotes can be found on the next page.

This institution is an equal opportunity provider. March 2017

Read and Keep This Page

Endnotes

1. Serve two food items. Each food item must be from a different food component. Juice may

not be served when milk is served as the only other component.

2. Must be served as a beverage, or on cereal, or use part of it for each purpose.

3. Must be served as a beverage.

4. Serve two or more kinds of vegetable(s) and/or fruit(s) or a combination of both. Full-

strength vegetable or fruit juice may be counted to meet not more than one-half of this

requirement.

5. All grain/bread items must be enriched or whole-grain, made from enriched or whole-grain

meal or flour, or if it is a cereal, the product must be whole-grain, enriched or fortified.

Bran and germ are credited the same as enriched or whole-grain meal or flour.

6. Either volume (cup) or weight (oz.) whichever is less.

7. Must meet the requirements in Appendix A of the SFSP regulations.

8. No more than 50 percent of the requirement shall be met with nuts or seeds. Nuts or seeds

shall be combined with another meat/meat alternate to fulfill the requirement. When

determining combinations, l oz. of nuts or seeds is equal to 1 oz. of cooked lean meat,

poultry, or fish.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights

regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or

administering USDA programs are prohibited from discriminating based on race,

color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any

program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g.

Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local)

where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may

contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may

be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint

Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA

office, or write a letter addressed to USDA and provide in the letter all of the information requested in the

form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to

USDA by:

(1) mail: U.S. Department of Agriculture

Office of the Assistant Secretary for Civil Rights

1400 Independence Avenue, SW

Washington, D.C. 20250-9410;

(2) fax: (202) 690-7442; or

(3) email: program.intake@usda.gov.

This institution is an equal opportunity provider. March 2017

UPWARD BOUND AND UPWARD BOUND MATH SCIENCE AT BOSTON UNIVERSITY STUDENT REGULATIONS

Program Authority

Students are expected to abide by stated program regulations and follow the directives of their course instructors,

tutors and counselors. Students may individually or collectively make recommendations concerning all aspects of program

operations. All recommendations will be carefully considered by the program's administration.

Students Regulations

The following regulations are divided into two groups: Group I and Group II. The first group is divided into two

sub groups: Group IA and Group IB. Group IA is infractions of a more serious nature and will, under no circumstances be

tolerated. Violation of Group IA regulations will result in immediate dismissal from the program! No exceptions will be

made!

Group IA - There is to be no:

1. Possession or use of illegal drugs or alcoholic beverages.

2. Taking of another person’s property without that individual’s permission.

3. Physical violence or the threat of physical violence.

4. Possession or use of weapons or fireworks.

5. Intentional destruction of property, including graffiti.

6. No visiting on ANY program’s residence floor reserved for the opposite sex nor should there be any sexual

activity at any time or place.

7. Throwing of articles of any kind from the residence hall windows.

8. Students may not use the residence or dining halls outside of approved times.

A first violation of Group IB will result in a student’s losing evening free time for a Monday, Tuesday, Wednesday and

Thursday, which means a 9 p.m. curfew on tutor team meeting and activities nights and a 7 p.m. curfew on the night a student

has no programming scheduled . A second violation of Group IB will result in the student’s dismissal from the program.

Group IB - There is to be no:

1. Students should not leave campus, which in this instance is defined as the area along Commonwealth

Avenue between Kenmore Square and Packard's Corner (Shaw’s Market). Beacon Street, Brookline

Avenue (beyond Popeye’s), and Lansdowne Street are outside of this geographic area. Students may use a

limited section of the Esplanade (from the Boston University bridge to the dock nearest to the Bay State

Road footbridge) to utilize the roller blade and bike paths. The Esplanade may only be used until 9 p.m.

2. Breaking curfew. (Student’s must be on a UB assigned residence floor by 11 p.m. and in their designated

dormitory room from midnight until 5:30 a.m. Students must remain in the residence hall until 7 a.m.)

3. Failure to notify staff person of a change in intended destination without valid explanation. Students

cannot be outside the residence hall after 7 p.m. without having signed out.

4. No unauthorized visitors on campus. (Campus is defined as in or immediately surrounding Boston

University Buildings) Immediate family and program alumni are authorized visitors on campus.

Immediate family may sign into the residence hall with the approval of Upward Bound staff.

Group II Regulations

The second group of regulations is subject to the following conditions:

a. If the program administration has determined that a student has violated any one of the following

regulations one time, the student will receive a written warning.

b. In the event of a second violation, the student will receive a second written notice, and the student’s

Parent/Guardian will be advised by telephone and/or in writing.

c. In the event of a third violation, the student will be placed on probation. The student's

Parent/Guardian will be asked to come in for a meeting with the program's administrative staff.

If a student breaks any Group II regulations while on probation, they will be dismissed from the summer program.

Group II - There is to be no:

1. Disrespectful or disruptive behavior, including pranks.

2. Repeated tardiness to, absence from or lack of preparedness for classes and activities.

3. Use of profane language in communicating with staff and students.

4. Cigarette smoking or use of other tobacco products by any student under 18 years of age. Smoking will not

be tolerated in areas where it is prohibited.

5. Failure to comply with directives issued by program staff without reasonable explanation.

6. Students may not use cell phones or other mobile communication devices during classes or other program

activities. Any student caught using such items under these circumstances will have it confiscated by

program staff and returned at the end of the week.

7. Academic dishonesty (cheating, copying or allowing others to copy assignments, or plagiarism).

Updated 9/28/15