SUNY Poly Youth Activity Certification Page (Faculty/Staff)

Registration Form for University Sponsored Youth Programs & Activities

In compliance with the SUNY-wide Child Protection Policy, members of the campus community who plan to host a campus sponsored youth program or activity, must complete this registration form in advance of the scheduled event. All youth programs are required to adhere to the policies and procedures pertaining to the Child Protection Policy.


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Name of Program Coordinator(Required)
Program Coordinator's Email Address(Required)
Type of Youth Program(Required)
Program or Activity Format(Required)
Program Start Time (am/pm)(Required)
Program End Time (am/pm)(Required)
Program or Activity Audience (check all that apply)(Required)
Who will be responsible for the custody, control and supervision of youth for the duration of the program (check all that apply)(Required)
Does this youth program require overnight accommodations?(Required)
Does this youth program require use of locker rooms?(Required)
Is this a private instruction youth program? (ex. individual music lessons, etc.)(Required)
Will parents be completing a photo release form prior to their child(ren) participating in the youth program?(Required)
Will parents be completing a health release form prior to their child(ren) participating in the youth program?(Required)
Max. file size: 50 MB.
Please upload (Excel Format) a list all faculty, staff, students and volunteers of the University who will be responsible for custody, control and supervision of the children during this youth program. The list MUST include ALL of the following information: 1. Full, legal name of each participant (full first and last name – no nicknames) 2. Valid email address for each participant and 3. Date of Birth for each participant. Once this list has been received, they will be invited to complete the required training and a required sex offender registry search will be performed.
Certification (*Please check both boxes*)(Required)
As the program coordinator for this youth program, by checking the boxes below, I agree to abide by all the requirements outlined in the SUNY-wide Child Protection Policy ( and the Policy on Mandatory Reporting and Prevention of Child Sexual Abuse (
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