Submit REGISTRATION FORM for PROGRAM WITH MINORS It is the policy of Belmont University that any program, activity, service or event involving minors, on or off campus, sponsored by any academic administrative or athletic department of Belmont University; or programs, activities, services or events involving minors, on or off campus, sponsored by non-Belmont, external entities, using University facilities, must be registered with Office of Risk Management and Compliance prior to the commencement of such program, activity, service or event Return this form to: riskmanagement@belmont.edu and hr@belmont.edu PART 1: Date Submitted: _ Program/Activity/Event Coordinator (Primary Contact) First Name: _ Last Name: _ Title: _ Department/Organization: _ Email: _ Address: _ PART 2: PROGRAM INFORMATION Name of Program/Activity/Event: _ Brief Description of Program/Activity/Event: External Entity/Individual partnering with Belmont: _ Location(s) of Program/Activity/Event: _ (Please specify building/room) Days/Dates/Times of Program/Activity/Event: _ Begins: _ Ends: Number of Minors (Please specify if Estimation): Early Childhood Students (Pre K-2): Elementary Students (3-6): Middle School Students (7-8): High School Students Male (9-12): Female Both Does the Program/Activity/Event require overnight housing? Yes No Does the Program/Activity/Event require Belmont transportation? Yes No Updated 1-3-18 | BELMONT UNIVERSITY REGISTRATION FORM for PROGRAM WITH MINORS PART 3: REQUIRED BACKGROUND CHECK FOR HUMAN RESOURCES Program Directors: Please complete the information below for all faculty, professional staff, students, volunteers or contractors participating in the Program/Activity/Service/Event Every individual is required to have fully complied with State Law and Belmont University Policy concerning: Background check must be updated every four (4) years Protection of Minors/Mandated Reporting of Child Abuse Training Background checks and Protection of Minor Training must be completed two (2) weeks before the program begins For additional space, please format in an excel spreadsheet *Legal* First Name Last Name Fund Org Last of SS# Email Address Cell Phone # Account Program Program/Event Activity Please inform all faculty, professional staff, students, volunteers or contractors participating in the Program/Activity/Service/Event of the following: Required background screening: * With the requested information (email and cell #), HireRight will send an email as well as a text message to the potential employee/chaperone/volunteer to complete the needed information to begin the background check Once information is received from HireRight via text/email, please complete immediately *If you not see an email from HireRight in your regular inbox, please check your spam inbox Required Training Information *Before being allowed to work any program/event as a camp worker/chaperone and/or volunteer, you are also required to complete training on Belmont’s Protection of Minors on Campus policy Please click on the link below to access the online training http://www.belmont.edu/risk-management/protecting-minors.html Who’s Responsible? It is the responsibility of the person in charge of the Program (Program Director) to ensure that each participating adult has completed the required background check and has completed the Protection of Minors Training Once this form is completed submit to the Office of Risk Management and Compliance and Human Resources riskmanagement@belmont.edu and hr@belmont.edu Updated 1-3-18 | BELMONT UNIVERSITY