Request Form - Risk Mgmt - Minors Program Certification of Compliance

Program Coordinators must submit this Certificate of Compliance to the Office of Risk Management (ORM) at least five business days prior to the start of the Minors Program. Failure to timely submit this form will result in immediate cancellation of the event.

Name of Minors Program

Start Date

End Date

Minors

Number of Minors

(17 years of age or younger at the time of the event)

Approved as Exempt

Check this box if this Minors Program has been approved as Exempt by the Assistant Director, Risk Management.

Exempt

Supervising Adult Information

No student, University employee, parent or legal guardian, independent contractor or other volunteer shall serve as an Supervising Adult in any University-sponsored Program, unless and until the appropriate clearances have been obtained and the required training has been completed.

All Supervising Adults are required to be 18 years of age or older.

First Name

Last Name

Phone Number

Add additional Supervising Adult?

Yes

No

First Name

Last Name

Phone Number

Add additional Supervising Adult?

Yes

No

For more than 10 Supervising Adults, please use the following spreadsheet:
Minors Program Spreadsheet

First Name

Last Name

Phone Number

Add additional Supervising Adult?

Yes

No

First Name

Last Name

Phone Number

Add additional Supervising Adult?

Yes

No

First Name

Last Name

Phone Number

Add additional Supervising Adult?

Yes

No

First Name

Last Name

Phone Number

Add additional Supervising Adult?

Yes

No

First Name

Last Name

Phone Number

Add additional Supervising Adult?

Yes

No

First Name

Last Name

Phone Number

Add additional Supervising Adult?

Yes

No

First Name

Last Name

Phone Number

Add additional Supervising Adult?

Yes

No

First Name

Last Name

Phone Number

Requirements

Clearances obtained for each Supervising Adult

Yes

No

Training completed by each Supervising Adult

Yes

No

Permission, Legal Release and Emergency contacts obtained for each minor

Yes

No

Supervision plan implemented

Yes

No

Virtual/online programming compliance implemented

Yes

No

N/A

Certificate Of Insurance

Yes

No

N/A

Volunteer Agreement

Yes

No, All SAs are DU employees or students

Information Submitted Certification

I certify that the information submitted above is accurate and that this Minors Program is compliant with Duquesne University policies under TAP 50 – Protection of Minors and the Compliance Manual for Minors Programs

I certify that the information submitted above is accurate

Program Coordinator Full Name

Program Coordinator Email

Submission Date

Your name

Your email address

Verification Code

Risk Mgmt - Minors Program Certification of Compliance

Minors

Supervising Adult Information

Requirements

Other Fields

Service Providers