Program/Activity Registration: Middle Georgia State University

Name of Program/Activity

Sponsoring Department/Unit

Point of Contact

Name

Title

Email

Phone (24 hour)

Program Administrator

Sponsoring Department/Unit’s Dean/Director/VP

Name

Email

Activity Information

Program Activity Offered by a

University Student Organization
University Employee/Department/Unit
Third Party using University Facilities

Department or Third Party Name

Dates and Times

How many sessions will be held

Type of Program/Activity (Choose one)

Academic
Admissions
Athletic
Camp
Conference
Experiential Learning
Recreational
Other

If Other, please explain

Description of program/activity

Location (can choose more than one)

Macon Campus
Cochran Campus
Dublin Campus
Eastman Campus
Warner Robins Campus
Macon-Downtown Airport
Off-Campus

If Off-Campus, please explain

Will the program require any transportation?

Yes
No

Will the Program utilize Middle Georgia State University Laboratories?

Yes
No

Number of participants (estimated)

Minimum age of participants

Maximum age of participants

Number of MGA staff involved

Number of MGA student volunteers

Number of non-MGA staff volunteers

Who will chaperone the minor participants?

Will Program Staff/Volunteers have direct contact with non enrolled minors?

Yes
No

Will the program be overnight?

Yes
No

Please list any potentially dangerous activities that could take place with your program and explain how risk will be mitigated.

Eligibility

Will this be a public event open to the general public and which Minors attend at the sole discretion of their parent(s) or guardian(s)?

Yes
No

Will this be a field trip supervised by staff from the Minor’s school or organization?

Yes
No

Are all of the minors going to be supervised by a parent, guardian, or school for the entirety of the event?

Yes
No

Have you read the MGA Minors Policy?

*

I have read and agree to abide by all requirements in the MGA Minors Policy.

Digital Signature

First Name*

Last Name*

Email*

Once you receive electronic approval for your program, please remember to complete all background check requirements, mandatory training, required forms and the Programs Serving Minors Checklist before moving forward with your program. For any questions, contact Auxiliary Services at protectingminors@mga.edu.