Minors on Campus Instructions For additional information on the policy, training, background checks, please go to the Minors on Campus page. At least twenty-one (21) 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 Office of Compliance & Policy at email@example.com 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 fieldName 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 SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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:*Will this program require access to a Mines Computer Lab?*YesNoOther 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).Accepted file types: pdf.PDF files only; maximum file size: 15MB.