1. Review Protection of Minors Policy
2. At least fourteen (14) days prior to the event, complete and submit this form with
attachments to the Office of Compliance and Policy, Guggenheim Hall, 1500 Illinois
Street, Golden, CO. Email:
3. Contact Human Resources Department to request background checks per Minors

Program Title:
Hosting/Sponsoring Department:

Program Dates/Times or Beginning /End / Program Location

Program Director Contact Information:

Persons (at least 2) responsible for making arrangements for the safety of minors and
other participants in the event of an emergency (name, email address and phone
Contact 1:
Contact 2;
Estimated Number of Attendees (Include
Approximate Age Range of Participants:
Participants and Volunteers)

Summary of Program Description:

Attach a list of all Mines personnel (including student employees), volunteers, and
contractors who are or will be involved in this program. (Please note: Any individuals
who have not had a background check completed in the past 5 years will be required to
complete the Background Investigation Disclosure and Authorization Form)

I attest that I have reviewed Colorado School of Mines Protection of Minors Policy,
and that the information contained herein and attached (if applicable) is true and
correct to the best of my knowledge and belief.

Signature of Hosting / Sponsoring Department Head or Director