PLEASE REGISTER YOUR PROGRAM Please Register Your Program Name Of Program Contact Person Contact Person’s Email Address Contact Person’s Phone Number Program Sponsor Center For Leadership And Involvement The University Of Chicago Community Service Center Neighborhood Schools Program Other, Please Indicate Department And/Or Unit Entity Not Associated With The University of Chicago If Non-UChicago Entity, Please Indicate Name Of Entity If Non-UChicago Entity, Does Entity Have A Site Agreement? Yes No Overnight Activity? Yes No Program Start Date Program End Date How Many Minors Will Be Served? What University Locations Will Be Used To Host Minors? Ages Of Minors 5 years and under 5-8 years old 9-12 years old 13-15 years old 16-17 years old How Many Persons Will Have Direct Contact With Minor(s)? Name Of Person With Direct Contact With Minor Email Address Of Person With Direct Contact With Minor Name of Person With Direct Contact With Minor Email Address If There Will Be More Than Two Persons With Direct Contact With Minor, Please List Names and Email Addresses Have The Persons With Direct Contact With Minors Completed A Background Check? Yes No Yes, upon hire All persons that will have direct contact with minors are required to undergo a background check. Please use the form below to submit names and email addresses of persons that are required to have a background check. Upon completion of the form, please submit the form to firstname.lastname@example.org Background check form PLEASE SUBMIT YOUR PROGRAM REGISTRATION *”Direct Contact” means to provide instruction, care, supervision, guidance to, or oversight and/or control over children through a covered program.