Please complete this form at least twenty-one (21) days prior to your event.
For help or questions when completing this form email the
Office of Compliance at
email@example.com or see the Protection of Minors page. Note: If a required field is not applicable to your group, simply type N/A in that field.
Organization and Contact Information Who is submitting this form? (Required) Name of person completing this form (Required)
Needed if a non-Mines organization only
Name of the sponsoring department head or director. (Required)
I attest that I have the approval of the sponsoring department head or director. (Required) Information About Your Program Detailed Program Description: (Required) Type of Activity (Required) Please list the program: dates, beginning and ending times, and frequency. (Required)
Please include both the beginning and ending times.
Please note the frequency such as weekly, bi-weekly, annually, one time only.
Program Location(s) (Required)
On Campus Event: list all buildings/locations. Off Campus Event: please provide the name and address of the location (e.i., Smith Elementary School, 123 School Dr., Schoolville, CO 80000.) Remote/Online Event: Please specify and describe how contact with minors will take place.
Will this program require access to a Mines laboratory space or maker space? (Required)
Note: Minors are not allowed in machine shops.
Yes No Will this program require access to a Mines computer lab? (Required) Yes No Additional Emergency Contacts (Required)
Please list two additional people responsible for making arrangements for the safety of the minors and other participants in the event of an emergency. For each person list: Name, Email and Phone number.
Additional Emergency Contact - #2 (Required) Information about the Minor Participants Will the minors be accompanied by parents or adult chaperones? (Required) List Minor Participants by Age Group (Required)
Please enter the number of minors in each age group. If no minors from an age group will participate enter "0".
Information about the Adult Supervisors/Volunteers
In this section you will provide information about the adult supervisors/volunteers. The Mines Policy on the Protection of Minors requires that all adults(persons over the age of 17) who will be working with minors complete a background check at least every two years. Background checks for Mines personnel participating in an event with minors will be completed by the Office of Compliance in conjunction with Human Resources.
Non-Mines entities will need to complete their own background checks and provide the documentation to the Office of Compliance.
Participating adult supervisors/volunteers (Required)
Please list all personnel (include volunteers, contractors, students and employees) who are involved and will have contact with minors in this program. Please provide the name, CWID, email and phone number for each adult. Note: Per the Protection of Minors Policy, any individuals who have not had a background check completed in the past 24 months will be required to complete one. Self-reporting is required of any arrest/conviction posing a risk to minors.
** To add more lines, click the Plus sign on the right hand side.**
2 3 4 5 - to Add more names click the "+" sign on right hand side Certification and Attestation Certification (Required)
I attest that I have reviewed the Colorado School of Mines Protection of Minors Policy and I understand that all adult participants must adhere to the policy during the event and complete any required training. I further agree that the information contained herein is true and correct to the best of my knowledge and belief.
ADDITIONAL INFORMATION FORM SUBMISSION