This form must be signed, and enclosed with a mailed Charter Application, by any proposed Member of a Steering Committee who is not a teacher or administrator currently employed at a Participating School or in a school system that includes one or more Participating Schools.
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.
Name: ___________________________________________________________
Mailing Address: ___________________________________________________
Town/State/Postal Code: ____________________________________________
Place of Employment: ______________________________________________
Title/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.
____________________________________________
Signature
____________________________________________
Printed
_____________________
Date