Request a Consent Form

Requestor's name

Email address

Name of the Program

Date(s) of the Program

Start and End Times of the Program

Location(s) of the Program

Who is responsible for supervising the minors during this program?

If the program is an internship, list the faculty member or research associate who is responsible for the minor.

What is the goal or mission of this program?

Describe all activities that will be conducted during this program. List any equipment (and any associated PPE) that will be used during the program.

Who is responsible for transportation to, from, and during this program? If Cornell is responsible for transportation, what vehicles will be used?

Will photos, video, or other media be taken during this program?

Do you need parent/guardian emergency contact information captured on the consent form? Yes/No