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: ___________________________________________________________

STREET ADDRESS: ___________________________________________________________

TOWN/STATE/ZIP: ___________________________________________________________

PLACE OF EMPLOYMENT: ___________________________________________________________

POSITION: ___________________________________________________________

• I have not been convicted of, nor am I presently charged with, and felony offense.
• I agree to follow all Cappies rules and procedures.

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Signature

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Printed

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Date