Elizabethtown College
Facilities Management Special Events & Summer Programs
One Alpha Drive, Elizabethtown, PA 17022
Phone (717) 361-1203
Working with Minors Packet
The following six (10) page Registration of Minors on Campus Form must be
completed no later than thirty (30) days prior to the start of the Clinic/Program at
Elizabethtown College, and returned to:
Elizabethtown College
Special Events & Summer Programs
One Alpha Drive
Elizabethtown, PA 17022
OR
Electronically to: SESP@etown.edu
Please direct questions to the Special Events & Summer Programs Office phone
717.361.1418.
Elizabethtown College
Facilities Management Special Events & Summer Programs
One Alpha Drive, Elizabethtown, PA 17022
Phone (717) 361-1203
Registration of Minors on Campus Form
Covering Minor Participation in College Programs and Events
INSTRUCTIONS: Under the Elizabethtown College Policy Regarding Minors on Campus, if a College program or event involves the
participation of minors, this form must be completed with the required signatures and submitted to the Director of Human Resources,
no later than 30 days prior to the start of the Program or Event. College Program/Event organizers will be responsible for
communicating with the high school or minor associated group or individuals and providing them with a copy of the College’s Policy
Regarding Minors on Campus and the appropriate Release and Consent Forms included in the Working with Minors Packet. Please
contact the Director of Human Resources or the Human Resources Office at 717-361-1406 with any questions concerning this form or
the registration process.
DEFINITION OF A MINORA minor under Pennsylvania law, is an individual under the age of 18 years. For the purposes of this
policy, minors on the College campus are children under 18 years of age participating in programs, internships, camps or activities
on campus, whether or not it is a college sponsored program or through a third party.
I. GENERAL PROGRAM INFORMATION
Name of Department Organizing the Program/Event:
Dept.:______________________________, Elizabethtown College, One Alpha Drive, Elizabethtown, PA 17022
Name:________________ ____Email:____________________________ Phone:_________________________
Name of Program/Event:
Clinic:
Name of Director:
Email address: Phone Number:
Dates of Program/Event:
How will the Minors Participate in the Program/Event?
_____________________________________________________________________________________
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Elizabethtown College
Facilities Management Special Events & Summer Programs
One Alpha Drive, Elizabethtown, PA 17022
Phone (717) 361-1203
Who will be the “Authorized Adults” Supervising or Accompanying the Minors while participating in the
Program/Event? (Please list below, or use a separate sheet).
Authorized AdultAn authorized adult is an adult, age 18 or older, who is authorized, pursuant to this policy, to supervise, or
otherwise have Direct Contact with, minors participating in a Program. All College employees, students, independent contractors, and
volunteers (including but not limited to, Faculty, Staff, Students, Tutors, Instructors, Supervisors, Coaches, Camp Counselors, Program
Directors, Chaperones, Volunteers, Third Party Contractors, Vendors, and Temporary/Seasonal Workers) acting as authorized adults
must be in compliance with the requirements of the provisions of this Policy entitled “Individuals Acting as Authorized Adults.” Although
a parent or legal guardian may supervise their own minor children and their guests who are minors while visiting the campus or using
campus facilities, a parent or legal guardian may not act as an Authorized Adult in a Program (including one in which his or her child
participates) unless they are in compliance with the requirements outlined below under “Individuals Acting as Authorized Adults.”
Authorized Adults are considered Required Reporters.
II. COMMUNICATION PLAN
Please provide below or on a separate sheet a description of Communication Plan to be followed by the program.
The Communication Plan must include:
A procedure for obtaining and maintaining contact information for participants’ parents/legal guardians, as well as
emergency contacts in the event the parents/guardians are unavailable;
A procedure for notification of all participants’ parents/legal guardians in the event of an emergency; and
A procedure for parents and guardians to follow to contact program personnel and/or their child during program hours.
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Elizabethtown College
Facilities Management Special Events & Summer Programs
One Alpha Drive, Elizabethtown, PA 17022
Phone (717) 361-1203
III. MEDICAL EMERGENCY PLAN
Please provide below or on a separate sheet an outline of the Medical Emergency Plan to be followed by the Program. The
Medical Emergency Plan shall include:
A procedure for obtaining and maintaining (i) authorization from all participants’ parents/legal guardians to transport
program participants to local hospitals as deemed necessary; and (ii) authorization for emergency medical treatment in the
event the parents/legal guardians or their designated emergency contact are not available;
A procedure for obtaining and maintaining disclosures of any allergies or other medical condition or physical limitation that
might impact participation in the Program; and
A procedure to administer medication to program participants as necessary during program hours.
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Elizabethtown College
Facilities Management Special Events & Summer Programs
One Alpha Drive, Elizabethtown, PA 17022
Phone (717) 361-1203
IV. SUPERVISION PLAN
Please provide below or on separate sheet a description of the Supervision Plan to be followed by the program.
Please note that the Policy Regarding Minors on Campus prohibits any unobserved, unsupervised one-on-one contact between a
minor and any Authorized Adult. A Supervision Plan must specify:
The person having responsibility over all Authorized Adults serving in the Program;
The proposed ratio of participants to Authorized Adults;
The proposed number of Authorized Adults over 21;
The breakdown of Authorized Adults by category of employees, students and volunteers; and
Curfew, rules pertaining to any visitors, and limitations of use of free time in the event the Program involves any overnight
stays.
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Elizabethtown College
Facilities Management Special Events & Summer Programs
One Alpha Drive, Elizabethtown, PA 17022
Phone (717) 361-1203
V. TRANSPORTATION PLAN
Please provide below or on an attached sheet a description of the Transportation Plan to be followed by the program.
The Transportation Plan must include:
A procedure for the pick-up and drop-off of participants, specifying times and locations;
A procedure to obtain written permission from a parent or legal guardian in the event any participant is to be released to
any person other than his or her parents or legal guardians; and
A description of any transportation of participants to be provided by the program, specifying the type of vehicle, and
drivers. Under no circumstances shall an Authorized Adult be permitted to be alone with a minor in a car or other vehicle.
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Elizabethtown College
Facilities Management Special Events & Summer Programs
One Alpha Drive, Elizabethtown, PA 17022
Phone (717) 361-1203
Signatures_________________________________________________________________________
Program/Event Organizer: ________________________________________ _ Date ________________
Elizabethtown College:
Special Events & Summer Programs: ______________________________________________ Date ________________
Director of Human Resources: ____________________________________________ Date ________________
Copies To:
Program/Event Organizer
SESP, as appropriate
Protection of Minors File
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Elizabethtown College
Facilities Management Special Events & Summer Programs
One Alpha Drive, Elizabethtown, PA 17022
Phone (717) 361-1203
Working with MinorsSAMPLE FORM (We recommend you create a similar form
which will authorize you to obtain background information on the camp/conference
authorized adults).
Criminal Background Check Information & Inquiry Release For Students and Volunteers
Elizabethtown College’s Policy Regarding Minors on Campus provides that employees, students, volunteers, and third party
contractors who are expected to work directly with minors are required to successfully complete a criminal background screening
prior to beginning any assignment involving minors and to participate in required training. This requirement is fulfilled for staff and
faculty under the College’s Background Checks Policy, and third party contractors are required to screen their own employees
prior to beginning any such assignment.
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
I understand that I am covered by the Policy Regarding Minors on Campus as a student or volunteer who may be working directly
with minors, and I understand that my consent to such criminal background screening is a condition of my initial and continued
participation in any College program involving minors. I have carefully read the Policy Regarding Minors on Campus and this Consent
and Release Form, and I hereby consent to such criminal background screenings, including those performed by any consumer
reporting agency at the College’s request. This consent will continue to apply throughout the period of my participation in any such
College program to the extent permitted by law.
Reports prepared by a consumer reporting agency based on its criminal background screenings may constitute consumer or
investigative consumer reports as defined in the Fair Credit Reporting Act. Such reports may include federal, state or local criminal
history records or information pertaining to me, and other information concerning my education, qualifications, work experience,
character, general reputation, personal characteristics and/or mode of living. I hereby authorize any consumer reporting agency to
release and disclose, verbally and in writing, these reports and this information to authorized representatives of [camp/conference
name] within the terms of the Policy Regarding Minors on Campus.
I hereby authorize all persons and entities including, without limitation, educational institutions, my current and former employers,
government agencies and police departments, to disclose and provide all relevant records and information requested by a consumer
reporting agency or Elizabethtown College as part of any criminal background screening obtained pursuant to the Policy Regarding
Minors on Campus; and I hereby forever release and discharge (1) Elizabethtown College, (2) any consumer reporting agency that
performs any criminal background screening at the College’s request pursuant to the Policy Regarding Minors on Campus, and (3)
any person or entity including, without limitation, any educational institution, my current and former employers, any government
agency or police department that discloses or provides records or information requested by Elizabethtown College or any consumer
reporting agency as part of a criminal background screening obtained pursuant to the Policy Regarding Minors on Campus
(collectively, the “Releasees”), as well as all of the Releasees’ trustees, directors, officers, employees and representatives, from any
claims, suits, damages, losses, liabilities, costs or expenses arising as the result of or in any way related to their participation in the
performance of any background check, information verification, and/or other action taken pursuant to the Policy Regarding Minors on
Campus, to the fullest extent permitted by law.
I hereby certify that the information I have provided below is true and complete to the best of my knowledge. I understand that if any
such information is materially false or incomplete, it will be sufficient cause for termination of my participation as a student or
volunteer in any Elizabethtown College program covered by the Policy Regarding Minors on Campus, now or in the future. I agree
that this Consent and Release Form, in original, faxed, photocopied or electronic form, will be valid for any criminal background
screening, reports or other purposes under the Policy Regarding Minors on Campus.
Print Full Name ______________________________________________________________ Date of Birth* ___________________________
Social Security # _______________________________________ Driver’s License # ______________________________________________
Maiden Name ____________________________________________ Other Names Used ___________________________________________
Street Address ___________________________________________________________________________________________________________
City _______________________________________________________________ State __________________ Zip _____________________
Signature ____________________________________________________________________ Date ______________________________
*Date of birth is being requested only for the purposes of identification in obtaining accurate retrieval of records and it will not be used for discriminatory
purposes.
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Elizabethtown College
Facilities Management Special Events & Summer Programs
One Alpha Drive, Elizabethtown, PA 17022
Phone (717) 361-1203
Working with Minors
Adult Participant Information & Waiver Form
The information collected in this form is confidential and will only be shared in a medical emergency. Please complete all fields.
Attendee Information
Participant’s Full Name: __________________________________________________ Address: _____________________________________
City _______________________________________________ State: ________________________ Zip Code: ________________________
Home Phone Number: ___________________________________________ Cell Number: _________________________________________
Emergency Contact Information
(Contact #1) Name: _______________________________________________ Relation to Participant: _________________________________
Home Phone Number: ____________________________________ Cell Phone Number: ___________________________________________
Work Phone Number: ____________________________ Place of Employment: __________________________________________________
(Contact #2) Name: ______________________________________________ Relation to Participant: _________________________________
Home Phone Number: ____________________________________ Cell Phone Number: ___________________________________________
Work Phone Number: ____________________________ Place of Employment: __________________________________________________
Waiver/Release Information
I understand and agree that I am responsible for arranging my own health, accident, and liability insurance, and that no such insurance is
provided by ___________________________________ [insert Conference/Organization] and/or Elizabethtown College.
I hereby authorize the employees and/or agents of _______________________________________ [insert Conference/Organization] and/or
Elizabethtown College, at their sole discretion, to secure such medical advice and/or services as may be deemed necessary for my health and
safety, and I agree to accept full financial responsibility for such advice or services.
RELEASE AND INDEMNIFICATION. FOR MYSELF AND ALL THOSE WHO MAY CLAIM THROUGH ME OR IN MY PLACE, AND IN EXCHANGE FOR
AND IN CONSIDERATION OF ___________________________________________ [insert Conference/Organization] AND ELIZABETHTOWN
COLLEGE PERMITTING ME TO PARTICIPATE IN THIS CONFERENCE AND RELATED ACTIVITIES, I HEREBY ASSUME ALL THE RISKS OF INJURY
ASSOCIATED WITH THIS CONFERENCE AND RELATED ACTIVITIES AND AGREE TO RELEASE, HOLD HARMLESS, AND INDEMNIFY
___________________________________________________________________ [insert Conference/ Organization] AND ELIZABETHTOWN
COLLEGE, AND THEIR OFFICERS, AGENTS, AND EMPLOYEES FROM ANY AND ALL LIABILITY, ACTIONS, CAUSES OF ACTION, NEGLIGENCE,
CLAIMS OR DEMANDS OF ANY NATURE WHATSOEVER THAT MAY ARISE BY OR IN CONNECTION WITH MY PARTICIPATION IN THIS
CONFERENCE AND RELATED ACTIVITIES.
In signing this document I acknowledge that I am 18 years of age or older, that I have read it, that I understand it, that I have signed it
knowingly and voluntarily, and that I accept and intend to be legally bound by its terms.
Date: ____________________________________ Signed: _____________________________________________________________
Name Printed: ____________________________________________________________
This form must be completed, printed, and mailed, emailed (scanned as a PDF file), or faxed to the Conference/Camp Director.
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Elizabethtown College
Facilities Management Special Events & Summer Programs
One Alpha Drive, Elizabethtown, PA 17022
Phone (717) 361-1203
Working with Minors
Minor Participant Information & Waiver Form
The information collected in this form is confidential and will only be shared in a medical emergency. Please complete all fields.
Attendee Information
Participant’s Full Name: __________________________________________________________ Address: _____________________________
City: _______________________________________________ State: ________________________ Zip Code: ________________________
Home Phone Number: ____________________________________________ Cell Number: _________________________________________
Date of Birth: ___________________________________________________ Gender: ____________________________________________
Emergency Contact Information
(Contact #1) Name: ___________________________________________________ Relation to Participant: _____________________________
Home Phone Number: _________________________________________ Cell Phone Number: ______________________________________
Work Phone Number: _________________________________ Place of Employment: _____________________________________________
(Contact #2) Name: ___________________________________________________ Relation to Participant: _____________________________
Home Phone Number: _________________________________________ Cell Phone Number: _______________________________________
Work Phone Number: _________________________________ Place of Employment: ______________________________________________
Insurance Information
Health Insurance Company Name:
___________________________________________________________________________________________
Policy or Member ID Number: ______________________________________ Group Number: _______________________________________
In whose name is the insurance listed:
________________________________________________________________________________________
Medical Information
Is your child under medical treatment: Yes ________ No ________
List condition(s): __________________________________________________________________________________________________
Please list any medications your child currently takes:
Prescription: ____________________________________________________________________________________________________
Over the counter: _________________________________________________________________________________________________
Can your child self-medicate? ___________________________________________________________________________________________
Please check pain reliever that may be given: Tylenol ________ Ibuprofen ________ Other __________________________
Name of Family Doctor: _________________________________________________ Phone Number: ________________________________
List any physical conditions and explain treatment:
____________________________________________________________________________________________________________________
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Elizabethtown College
Facilities Management Special Events & Summer Programs
One Alpha Drive, Elizabethtown, PA 17022
P
hone (717) 361-1203
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Please list any pre-existing conditions or medical concern(s) that would limit your child’s participation:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Medication Permission
______________________________________________ has brought/will bring the following medications with him/her. He/she has my
(name of participant)
permission to use them. He/she may not share them with anyone else.
Medications:
____________________________________________________________________________________________________________
Parent/Guardian Signature: ___________________________________________________________ Date: ____________________________
I, ___________________________________________________, am aware that I may NOT share any medications with other participants.
Participant Signature: ______________________________________________________________ Date: ______________________________
Medical Treatment Authorization
In the event that medical treatment for my child is required, I authorize a representative of ____________________________________[Insert
name of camp/conference] to take my child to be treated at a nearby hospital. I also understand that my insurance is primary if medical
treatment is rendered.
Parent/Guardian Signature: _____________________________________________________________ Date: ______________________
Waiver/Release Information
I
n consideration for the permission granted by _______________________________________________ [insert name of camp/conference] for Minor to
participate in this Event, on my behalf and on behalf of the Minor, and each of my and the Minor’s heirs, executors, and administrators, I hereby waive and release
any and all causes of action, claims, suits, damages, and judgments, in any form whatsoever, arising from or by reason of any and all known or unknown, foreseen
or unforeseen bodily or personal injuries (including death) or property damage, resulting from the Minor’s participation in the Event and related activities, against
Elizabethtown College and ______________________________________________
[insert name of camp/organization], and their employees, administrators, trustees, volunteers, and agents.
IN WITNESS WHEREOF, and intending to be legally bound, I have executed this document below.
Signature of Parent/Legal Guardian: _______________________________________________________ Date: _________________________
This form must be completed, printed, and mailed, emailed (scanned as a PDF file), or faxed to the Director of the Program.
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