​SCHOOL AUTHORIZATION FORM
 
*Please submit this form by the grant application deadline date of March 25, 2019.
 
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 administrator in the PWSD):
 
_____________________________________________________________________________________
 
 
Staff for technology usage - including any usage of a computer or computer network:
 
_____________________________________________________________________________________
 
 
Applicants can submit this signature form by:

Email: info@heartspw.org
Mail:
HEARTS,
PO Box 1192 
Port Washington, NY 11050
 
Thank you!

---