Minors on Campus Form

Name of person completing this form*

First Last

Name of hosting/sponsoring department head or director*

First Last

I attest that I have the approval of the Colorado School of Mines hosting/sponsoring department head/director.*

Yes
No

Are you submitting this form on behalf of:*

a Mines program/activity (e.g., admissions/athletic event, lab tour, open to the community, etc.)
a Mines Student Group or Club (including Club Sports)
a non-university organization (e.g., a community group, rental, etc.)

Name

First Last

Email*

Enter Email Confirm Email

Phone*

Address

Needed if non-Mines personnel only

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

Program Title*

Hosting/Sponsoring Department (Group)*

Program dates/times*

Please include both beginning and end information.

Frequency of program/event*

Check all that apply

Daily
Weekly
Monthly
Annually (if annual, file form yearly)
Other (please specify below)

Other frequency

Please describe.

Type of activity*

Day Activity
Resident (overnight)
Both

Program Location(s)*

Please specify

Additional Contacts*

Please specify at least two people responsible for making arrangements for the safety of minors and other participants in the event of an emergency. Please include for each person: Name Email Phone number

Will the minor/youth be accompanied by adult chaperones?*

Yes
No

Estimated number of volunteers*

Number of participants

4-5 year olds*

Enter number of participants in this age range or N/A

6-8 year olds*

Enter number of participants in this age range or N/A

9-13 year olds*

Enter number of participants in this age range or N/A

14-17 year olds*

Enter number of participants in this age range or N/A

Detailed Program Description/Summary:*

Will this program require access to a Mines Computer Lab?*

Yes
No

Other information

Participating Mines Personnel*

Please list all Mines personnel (include volunteers, contractors, student employees) who are involved and will have contact with minors in this program. Please provide name, CWID and contact information. Note: Per the Protection of Minors Policy, any individuals who have not had a background check completed in the past 48 months will be required to complete the Background Investigation Disclosure and Authorization Form. Self-reporting is required of any arrest/conviction posing risk to minors on campus.

Certification*

I agree.

I attest that I have reviewed the Colorado School of Mines Protection of Minors Policy, and that the information contained herein is true and correct to the best of my knowledge and belief.

Attach a PDF file with additional information about your program (optional).

PDF files only; maximum file size: 15MB.

Minors on Campus

Instructions

Number of participants