Name of School System: ___________________________________

Name of School: __________________________  Principal: _______________

Library Media Specialist: _____________________________

School Address: ___________________________________

                              ___________________________________

School Phone Number: _____________________ Fax: ____________________

E-Mail Address: __________________________________________________

Library Media Supervisor: ____________________________

Address for above: _________________________________

                                      ________________________________

                                    _________________________________

Phone: ______________________ Fax: _______________________________

School Enrollment: ______________ Number of Teaching Staff: ______________

Number of Instructional Support Staff: _____________
 

______________________________ __________
Superintendent or Designee                                      date
 

______________________________ __________
School Library Media Supervisor                             date
 

______________________________ __________
Principal                                                                         date
 

______________________________ __________
Library Media Specialist                                              date