UMN Program Submission Form: Submission #883

Submission information

Submission Number: 883

Submission ID: 4421

Submission UUID: 5582987e-f2ca-488c-9329-feea444e70bd

Submission URI: /program-submission-form

Created: Fri, 09/15/2023 - 09:10

Completed: Fri, 09/15/2023 - 09:10

Changed: Tue, 09/26/2023 - 14:58

Remote IP address: 162.158.212.238

Submitted by: Anonymous

Language: English

Is draft: No

Webform: UMN Program Submission Form

Submitted to: UMN Program Submission Form

Please indicate which type of program you would like to submit: K-12 Youth Event/Program/Camp/Intern/Conference (In-Person and/or On line)

Basic Information

Program Title Honors Mentor Connection

Unit Wayzata High School

Link to Program Registration https://www.wayzataschools.org/cf_enotify/view.cfm?n=4239

Description (HMC) is an academic class offered to highly motivated learners who seek to perform research in a field of their interest.

Phone 763-734-6971

Email (point of contact for participants) [email protected]

Program Director/Leader Amanda Laden

Program Leader Email [email protected]

Program Information

Start Date Mon, 09/04/2023 - 00:00

End Date Sat, 12/30/2023 - 00:00

Months Offered Jan, Feb, Mar, Apr, May, Sep, Oct, Nov, Dec

Age 16, 17, 18

Estimated number of participants 20

Subject Science, Technology, Engineering, and Math

Program Location Twin Cities/Central MN- In-person, Twin Cities/Central MN- Virtual

Publish on Youth Central website? No

Staffing Information

Have all covered staff/volunteers passed a background check within the last three years? Yes

Have all covered staff/volunteers completed the Safety of Minors mandatory training via the Training Hub? Not yet

Will there be a minimum of two program staff on duty at all times who are 18 or older and two years older than the oldest participant? Yes

Will all program staff/volunteers/student workers receive an orientation? Yes

Safety of Minors Information

Have you planned appropriate physical environments to ensure quality learning environments and help prevent illnesses and accidents? Yes

Is there a plan to change facilities or modify activities for participants with special needs? Not applicable

Is there a plan to change facilities or modify activities in case of extreme weather? Not applicable

Have you assessed the environment to determine if minors need to be accompanied to the bathrooms? Not applicable

Is there a plan for the safe movement of minors? Yes

Do minors attend without a parent or other caretaker? Yes

Does the program collect and keep within easy access information on each participant including current medications administered during program time frame and contact information for parents/guardians? No

Do program staff know how to find and use this information? No

Has the program established and communicated practices to prevent accidents and illnesses, including adequate first aid and proper handling of medications? Yes

Does the program have emergency plans for fire, weather (e.g., tornado), toxic gas evacuations, unfamiliar packages, intruders, lost or missing children, and other emergencies? Yes

Has the program established and communicated to program staff appropriate procedures for addressing emergencies, accidents and illnesses? Yes

Will the program obtain a signed release of liability from all parents/guardians of minors prior to participation? Yes

Does the program lodge people overnight? No

Has the program operated previously? Yes

Were any incidents of suspected abuse known to have been reported to or by staff in the last year? No

Notification Date Fri, 09/15/2023 - 00:00

Will a minor be present in lab environment? Yes

In addition to the general release and waiver form, has each participants' adult caregiver signed off on the Labs Use Agreement Form (Paid Lab activity) or the Volunteers/Guests in Labs Form? Yes

Are you prepared to give a safety overview of the lab space? Yes

Do you require any enrolled college students using the lab to complete a specific training safety module related to the lab activity? Yes

Have you required the minors to also take the training module (this is a requirement). Yes

Do you need an additional HSRM risk assessment because chemicals, dust, fumes, vapors, gases, biological materials, radioactive materials or other substances may be present? No

Virtual Program Information

Is this a virtual program? No

I agree to the terms of service. Yes