SAMPLE

XYZ Charter

719 Fourth Street

Anytown, TX

361/555-1234

Volunteer Participation

in

Action Committees

I, __________________________________, agree to serve on the _____________________

Action Committee for the _______________________ school year.

_______________________________________ _________________________________

Parent/Guardian Signature Date

Please list all children attending XYZ Charter during the ___________________ school year.

Child’s Name Grade

___________________________________ __________________

___________________________________ __________________

___________________________________ __________________

___________________________________ __________________

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