PROGRAM REGISTRATION/APPROVAL FORM
INSTRUCTIONS:
Before you register your program, please read the Wilkes University Minors on Campus Policy. As part of the
registration, you will have to certify that you have completed all of the requirements of the procedures. If you
have done so, you are ready to proceed with your registration. Send the completed and signed registration form
to the attention of Chief Risk & Compliance Officer at least sixty (60) days prior to the first scheduled date of
participation by Minors. Completion of this form does not guarantee approval of your program.
PROGRAM INFORMATION:
Name of Program: ___________________________________________________________________________
Program Description: _________________________________________________________________________
Program Director: ___________________________________ Cell Phone Number: ______________________
Is this a new program (never operated before)? Yes No Years on Campus: _____________________
Is this program sponsored (in full or in part) by an office or department of the University? YES NO
University Sponsor Name: ________________________________ Department: _________________________
Does this program require an overnight stay? YES NO
PROGRAM DATE(S) AND LOCATION:
List current program dates: Start date: _______________________ End date: _________________________
Location: OUTDOOR FIELDS CLASSROOMS UCOM RAC MARTS GYM
DDD AUDITORIUM OTHER: _____________________________________________________
If off‐campus, where will the activities take place? _______________________________________________
Ages of minors eligible to participate: Check all that apply: 6–12 YEARS 13-17 YEARS
Estimated number of minors registered for each session ______________
Estimated number of minors residing in the residence halls ___________
Estimated Number and Type of Program Personnel:
WU Faculty ____ WU Students _____ Adult Volunteers _____ WU Employees _____
Yes, I am aware that the Wilkes University’s Minors on Campus Policy requires all adults working with program(s)
on the Wilkes campus are to have a current criminal back ground check completed and on file, successfully pass a
mandatory online training module on Sexual Abuse of Minors, read, sign and follow the required Code of Conduct
and that all program employees are knowledgeable about and know how to report sexual/physical abuse or
neglect and are obligated to immediately report such an incident to the proper authorities.
SIGNATURES:
Program Director Vice President / Dean
Printed Name: _______________________________ Printed Name: ___________________________
Title: _______________________________________ Title: ___________________________________
Signature: ___________________________________ Signature: _______________________________
Date: _______________________________________ Date: ___________________________________
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