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:*

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 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.

First Choice
Second Choice
Third Choice

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