Protection of Minors Event/Program Form

Instructions

  1. For additional information on the policy, training, background checks, please go to the Minors on Campus page. Protection of Minors Policy.
  2. At least fourteen (14) days prior to the event, complete and submit this form.
  3. For employee background checks, contact the Human Resources Department at (303) 273-3250, or go to the HR Forms page and click on Background Disclosure/Authorization and complete the form.
  4. For questions on policy or training contact the Compliance & Policy Department at TitleIX@mines.edu 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.


* 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.)
* 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 (for annual file form yearly)
Other :  
* Type of activity
Day Activity
Resident (overnight)
Both
* Program Location(s) - please specify
Enter email address here to receive copy of submitted form:
* Program Director Contact Information. Please include:

  • Name
  • Email
  • Phone
  • Address (if non-Mines personnel)

* Persons (at least 2) 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 # of Volunteers
* Estimated number of participants.

(Also, please specify the number in each
age range below, if known.)
4-5 year olds
6-8 year olds
9-13 year olds
14-17 year olds
* Detailed Program Description/Summary:
Other information
* 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
  • 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.
* 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.
Agree
Do Not Agree
* Name of Person completing form:
Date
* I attest that I have the approval of
the Colorado School of Mines
hosting/sponsoring Department
Head/Director.
Agree
Do Not Agree
* Name of Hosting/Sponsoring Department
Head or Director
Attach a file with additional information about your program (optional).



* required