I am the organizer of the program listed below. The Committee on Programs for Children and Youth has informed me that program staff members (as defined in the Policy on Health and Safety of Children and Youth) must do one or both of the following: Background Check Certification obtain background checks and/or Training Certification complete health and safety training and child abuse reporting training I certify that program staff members have completed the identified requirements. I understand that I may be subject to University disciplinary action if I inaccurately certify the completion of these requirements. Program Name * Number of Staff Members * Signature * Please type your full name. Your typed name will serve as your signature.