This form must be signed, and enclosed with a mailed School Application for a Participating School, by any Mentor selected by that Participating School who is not a teacher or administrator at that or any other Participating School or an employee of a school system that includes a Participating School.
NAMEName: ___________________________________________________________STREET ADDRESS
Mailing Address: ___________________________________________________________TOWN/STATE/ZIP:
Town/State/Postal Code: ___________________________________________________________PLACE OF EMPLOYMENT
Place of Employment: ___________________________________________________________POSITION
I affirm that:
- I have not been convicted of, nor am I presently charged with, and felony offense.
- I agree to follow all Cappies rules and procedures.