CONTACT INFORMATION
Name of Primary Applicant: ___________________________________________________________
Email: ______________________________________________________________________________
Telephone: ________________________________________________________________________
School/Organization Affiliation (if applicable) __________________________________________
Program Title _____________________________________________________________________
SIGNATURES OF AUTHORIZATION - please obtain signatures where applicable, but everyone needs to have the principal sign if this is a school grant
School Principal(s): ______________________________________________________________
Buildings and grounds staff - for anything with electricity etc. use on school grounds:
____________________________________________________________________________________
Teacher or Administrative Partner (if primary applicant is not a teacher or adminstrator in the PWSD):
Staff for technology useage - including any usage of a computer or computer network:
________________________________________________________________________________________
Applicants can submit this signature form by:
Email: info@heartspw.org
or
Mail: HEARTS, PO Box 1192, Port Washington, NY 11050
Thank You