Civic Engagement Immersion Registration

Academic Year:*
SCHOOL INFORMATION
School Name:*
Primary Contact Person:*
School District:*
School Address:
Street Address Address Line 2 City State ZIP Code
School County:*
School Phone:*
School Email:
Principal Name:*
Counselor Name:*
Local Newspaper:*
TEACHER INFORMATION
Teacher #1 Name:*
Teacher #1 Phone:
Teacher #1 Email:*
Teacher #1 Grade Level:*
Teacher #2 Name:*
Teacher #2 Phone:
Teacher #2 Email:*
Teacher #2 Grade Level:*
THANK YOU
The resources used and provided through Mosaic Life Care Foundation's emPowerU programming are unpublished, confidential and proprietary work simultaneously protected under copyright, trade secret and like laws of the United States and of other countries. All rights are reserved. These materials may not be reproduced, displayed, or distributed, nor may the information therein be used or disclosed, in whole or in part, by any individual or organization without the express of written permission of Mosaic Life Care Foundation.
- I have read, understand and am in agreement with the above statement.

SCHOOL INFORMATION