Adult/ Mentor Registration for Groups Working with Youth/ Children (under 18)

Any adult (18 years or older) who interacts with youth/ children (under 18 years old) in your program must be registered. Parents/ guardians who paritcipate in the program do not have to be registered. The Primary Contact(s) for your group is responsible for completing this form. If you have any questions, please email source@jhsph.edu or call (410) 955-3880.

First Name

Last Name

Email

Primary Phone Number

List all JHU programs you are affiliated with. Include only programs that work with youth/ children under the age of 18.

JHU School Affiliation

If you answered 'other' in the above field, please explain here:

Describe your role within the program(s) (e.g., mentor, supervisor, organizer, tutor, staff)

List last date (month and year) you had a criminal background check. If you're unsure or have never had one, insert "none".

Affiliation with Johns Hopkins University

If you answered 'other' in the field above, please explain here:

List any other relevant information you can think of in regard to working with minors: