Youth Protection Program Approval Form

ALL areas contained within a blue background are filled by the form.

Group

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ALL areas within a red border are required fields.

Youth Program Registration Form

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Signatures

Comments:

Legal First Name

Email Address

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Group

Location

Maximum No of Students allowed

Program Details

Legal Last Name

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Contact Phone #

Program Description:

Name

Group

Overnight Program

Full Day Program

Type

Half Day Program

Group

Begin Date

End Date

If the Program is ongoing, put end date one year from beginning.

Group

From

Participant Age Group in Years

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Primary contact

Group

Monday

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Tuesday

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Wednesday

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Thursday

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Friday

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Saturday

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Sunday

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Start Time

End Time

Total Hours

Days

Additional contact

Youth Program Requestor Details

Group

Program has been approved by the supervisor or Department Head

I understand all updates to the form must be completed 5 days prior to Start Date

I have read and will abide by

Oakland University Youth Protection Policy

Accept Agreement

Electronic Signature:

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Approver Name:

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Group

Forward to email :

Group

Comments by OUPD :

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If you have any questions, please contact the Youth Protection/Cleary Act Coordinator at (248) 370-3867 or OUPD at (248) 370-3000.

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