Minors on Campus Form Minors on Campus Instructions For additional information on the policy, training, background checks, please go to the Minors on Campus page. At least fourteen (14) days prior to the event, complete and submit this form. For employee background checks, contact the Human Resources Department at 303-273-3250, or go to the HR Forms page and select Background Disclosure/Authorization and complete the form. For questions on policy or training contact the Compliance & Policy Department at email@example.com or (303) 273-3260 or see the Minors on Campus page.   Note: If a required field is not applicable to your group, simply type N/A in that field. * Required field 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.*YesNoAre 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*AddressNeeded if non-Mines personnel only Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe 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 frequencyPlease describe. Type of activity*Day ActivityResident (overnight)BothProgram 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 numberWill the minor/youth be accompanied by adult chaperones?*YesNoEstimated number of volunteers* Number of participants 4-5 year olds*Enter number of participants in this age range or N/A6-8 year olds*Enter number of participants in this age range or N/A9-13 year olds*Enter number of participants in this age range or N/A14-17 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 ChoiceSecond ChoiceThird Choice Attach a PDF file with additional information about your program (optional).Accepted file types: pdf.PDF files only; maximum file size: 15MB.