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: ______