SUMMER SCHOOL FOR UNDERGRADUATES

RESIDENTIAL PROGRAM INFORMATION SHEET

FORM COMPLETION

INSTRUCTIONS

Complete the below form and upload the files requested. ALL FIELDS ARE REQUIRED. Additional fields may appear based on your responses to previous questions. This informational form and all requested files must be received by May 16, 2025. After the form is completed, if applicable, Adriana Cabiedes will be in contact via email to confirm travel arrangements. Contact adriana.cabiedes@rochester.edu with any questions.

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"*" indicates required fields

Participant Name*

First Last

Email*

Enter Email Confirm Email

Home / Permanent Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Travel Information

Access to the dorm is Sunday, June 1, 2025, until Saturday, June 7, 2025. Check-in is available from 8:30 AM ET – midnight ET.

Will you drive a vehicle to the University of Rochester?

Yes

Will you keep your car on campus during the program?

Parking permits are required Monday – Friday from 7:30 AM to 7 PM ET.

Yes

Required Information for a Parking Permit

Cell Phone

Make and Model of Vehicle to be Used

License Plate Number

Issuing State of License Plate

Travel to Rochester

How will you travel to Rochester?

Note: for air travel, check the airline baggage size and weight restrictions and fees. Keep all checked luggage fee receipts and we will reimburse you.

By Air

By Train

By Bus

Will you make your own travel reservations?

The University of Rochester is happy to arrange your air, train, or bus travel on your behalf. This way, the University of Rochester pays for the cost of your roundtrip, domestic, economy travel up front and you will not have to wait for reimbursement.

If you would like to arrange for your own travel, you must send details ASAP to adriana.cabiedes@rochester.edu. Save all itemized receipts showing proof of payment to be submitted electronically. You will be reimbursed within 30 days after the end of the program.

Yes

No, I would like the University of Rochester to arrange my travel.

Required Information if Rochester is Making Travel Reservations

Legal Name

Type EXACTLY as it appears on the government issued ID you will use for travel.

First Middle Last Suffix

Departure Airport/City and State Name and Preferred Departure Time Range

If you have identified a specific flight, name the airline, departure city and state/airport name, exact departure time, flight number, layover city and state name(s), and exact arrival time to ROC. If you have identified a specific train or bus, name the train or bus company, departure city and state name, route number, exact departure time and exact arrival time to the Rochester, New York, station (same station for trains and buses).

Arrival Airport/City and State Name and Preferred Arrival Time Range

If you have identified a specific flight, name the airline, exact departure time from ROC, flight number, layover city and state name(s), exact arrival time, and arrival airport/city and state name. If you have identified a specific train or bus, name the train or bus company, route number, exact departure time from Rochester, New York, arrival city and state name, and exact arrival time.

If traveling from the West Coast, are you willing to take an overnight flight?

Yes

Not applicable

Emergency Contact Information

In case of emergency, please contact:

Emergency Contact 1: Name*

First Last

Emergency Contact 1: Cell Phone*

Emergency Contact 2: Name*

First Last

Emergency Contact 2: Cell Phone*

Medical Information

This information and a copy of your insurance card are required.

Medical Insurance Carrier*

Insurance Policy ID #*

Name of Policy Holder*

First Middle Last Suffix

Upload photos of your medical insurance card: front and back.*

File name format should be "LastName-FirstName-Insurance-Front" and "LastName-FirstName-Insurance-Back."

Drop files here or

Accepted file types: pdf, png, jpg, docx, doc, Max. file size: 5 MB.

List your dietary restrictions and food allergies

Medical Conditions

Please note below any medical conditions (for example, asthma, allegies) that could affect your participation in any way and so that we are better able to assist you in an emergency.

Upload proof of NYS required vaccinations*

Students must meet the New York State and University of Rochester immunization requirements.
Download the Immunization Requirements informational sheet.
File name format of your immunization record should be "LastName-FirstName-Vac." Use numbers at the end of the file name if you are uploading more than one file.

Drop files here or

Accepted file types: pdf, png, jpg, docx, doc, Max. file size: 5 MB.

Program Attestation*

SCROLL WITHIN THIS BOX TO READ ALL POINTS.

It is understood that I will perform research during the normal business hours of the University and that I will follow standard safety practices while in the laboratory and will direct questions regarding safety and procedures to the supervisor.

I consent that the program group photo may be posted on the program website.

I will complete all program surveys.

By checking the above agreement box, I certify that I am currently enrolled as a full-time or part-time student in an accredited US college or university.

I agree.

Student Ground Rules*

SCROLL WITHIN THIS BOX TO READ ALL POINTS.

It is important that all participants follow a few basic ground rules. We ask that you carefully read the following. Some of what you read below may seem obvious, but experience has shown that it is best to state expectations at the beginning.

Attendance on time when expected is required.

There are absolutely no illegal drugs or weapons allowed on campus.

There is no smoking or vaping in any building or doorway on the University campus.

Show respect to people and facilities, including fellow students, instructors, visiting speakers, all members of the University Community, classrooms, lab equipment, and all University property.

No unwelcome physical contact, verbal comments, or cyber bulling will be tolerated.

The use of cameras, imaging, or digital devices is prohibited where privacy is expected.

Take responsibility for your own actions. Clean up after yourself.

Speak up! If you have an idea or concern, let us know! Come with a positive attitude and an open mind. Be ready to learn and willing to try new things. If any problem arises, we will find a way to work them out.

I have read and understand the ground rules and agree to follow them.

Name

This field is for validation purposes and should be left unchanged.