Teachers College Office of Public Safety Form # OPS.M.2015.201
Registration - College Sponsored Programs hosting Minors on campus
Program: ______
Sponsoring Office/Department: ______
Location of Program Office on campus:______
Location of Program activities on campus (other than Program Office): ______
______
______
Is this a new Program? Yes If yes, planned start date: ______ No
Program overview: ______
______
______
Program website address (if applicable): ______
Program Director: ______TC Office Phone: ______
Primary Program Contact: ______Title: ______
Email: ______TC Office Phone: ______
Mail Stop: ______Cell Phone: ______
Secondary Program Contact: ______Title: ______
Email: ______TC Office Phone: ______
Mail Stop: ______Cell Phone: ______
Program staff: TC Faculty: ______Professional Staff: ______College Work Study :______ Adult Volunteers: ______ Student Employees: ______ Other ______
Program schedule (dates): Ongoing each academic semester (Fall and Spring)
Ongoing each summer (session#1 and/or #2)
As scheduled-
Planned dates for next Program event:
______
Recurring Program events:
______
Program Schedule (days of the week and times of the day):
______
Does this Program include an off-campus/off-site component? Yes No
(If YES, please list off-site location(s)):
______
Ages of Minors eligible to participate (check all that apply): 0-5 6-12 13-17
Estimated number of Minor participants for each regularly scheduled Program event/session:
______
Supervision ratio (Authorized Adult to Minor): ______
Does the Program use/maintain Authorizations/Waivers and Releases approved by the TC General Counsel for:
Participation: Yes No
Photographs: Yes No
Medical: Yes No
EMS: Yes No
Medication: Yes No
Transportation: Yes No
Audio and/or Visual Recording: Yes No
Others: ______
Does the Program maintain compliance with the requirements and regulations of:
NYC Department of Education (DOE): Yes No
NYC Department of Health (DOH): Yes No
Does the Program successfully complete personnel background investigations that meet the requirements of DOE and/or DOH for all Authorized Adults serving in the Program?
Yes No Frequency: ______
College Sponsored Programs hosting Minors on campus should complete this registration form, along with the attached Authorized Adult Roster, and the attached Background Waivers and Self Disclosures for all Authorized Adults, and return all to the TC Office of Public Safety, Mail Stop 225, Suite 1A Whittier Hall, Attention: Assistant Director, Investigations. The TC Office of Public Safety shall provide a copy of the Program registration form to the TC Office of School and Community Partnerships, and the TC Office of Risk Management. Authorized Adult rosters and Background Waivers and Self Disclosures shall be maintained in confidential and secure files at the Office of Public Safety.
College Sponsored Programs hosting Minors on Campus must comply with Teachers College Policies and Guidelines for the Supervision of Minor Children on Campus.
As the Director of this College Sponsored Program hosting Minors on campus, my signature below certifies that I have received, read, and understand the Teachers College Policies and Guidelines for the Supervision of Minor Children on Campus, and agree to comply with the Teachers College Policies and Guidelines for the Supervision of Minor Children on Campus.
Program Director: ______
(Please print name)
Signature: ______Date of signature: ______
………………………………………………………………………………………………….…………………………………For Office of Public Safety use only:
Received: ______
Site visit: ______Program staff meeting: ______
AA review: ______Program training: ______
Comments: ______
Form # OPS.M.2015.201