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  • Affirmation

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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: ______

Title/Position: _____________________________________________________

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