Minor’s Program Registration Form

Covered Activity Title(Required)

Activity Organizer's Name(Required)

The adult individual recorded as the primary contact and the lead responsible party for ensuring 1) adequate planning and preparation for a Covered Activity, 2) the implementation of planned safety protocols for the protection of Minors as appropriate to the Covered Activity, and 3) compliance with the policy throughout the planning and operation of a Covered Activity.

Activity Organizer's Email(Required)

Activity Organizer's Phone(Required)

Covered Activity Type(Required)

Covered Activity Additional Type(Required)

All use of recreation facilities/fields must be reserved through campus recreation.

Description of Covered Activity(Required)

Date(s) of Covered Activity(Required)

Length of Covered Activity(Required)

(e.g. 9am-2pm, full day camp or overnight)

Location of Covered Activity(Required)

Building name(s), field or off-campus location(s)

How long has this Covered Activity been operating?(Required)

(e.g. 2 years, new)

Covered Activity Accommodations(Required)

Campus Housing

Campus Dining

Transportation of Minors

None of the above

Please check all that apply.

Maximum # of Minor Participants(Required)

Age Range of Minor Participants(Required)

Academic discipline related to learning experience (if applicable)

Is the program part of a grant or department sponsored program?(Required)

I certify background checks will be conducted per the policy and procedures.(Required)

Confirm Prior to the start of any Covered Activity, all Activity Organizers and Activity Staff must complete (or have completed within the previous 12 months) a criminal background check satisfying the requirements detailed in the accompanying procedures, with the entire corresponding report yielding no disqualifying adverse results.

Covered Activity Website

You will be required to supply the following information after you submit this form to Risk Control and Insurance. 1. Personnel List, 2. Program Itinerary, 3. Marketing Material about the Camp/Event. 4. Third Party Program information including Facility Use Agreement and Certificate of Insurance.