Power Lunch Application Personal InformationName First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email PhoneGenderMaleFemaleDate of Birth MM slash DD slash YYYY Work InformationCompany Name Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneSupervisor ReferencesPlease provide two references (business and personal)NamePhone Mentoring InformationI am interested in reading at:M.C. Smith Elementary SchoolI would prefer to read to a:No PreferenceGirlBoyDays available: Select All Monday Tuesday Wednesday Thursday Friday If you heard about Power Lunch through a friend or colleague, please list their name: AcceptancePlease read the following: I understand the Program Policies and agree to adhere to them. I agree to abide by all the policies of the Hudson City School District. I will represent my community and Hudson Reads with professional demeanor. I will inform Hudson Reads if there is a change in my schedule, employment, or contact information. I give Hudson Reads permission to use my picture in a variety of media efforts. Consent* I agree to the policies and procedures. By checking this box I agree to the policies and procedures of the Hudson Reads Program and that all of the information on this form is accurate and complete, to the best of my knowledge.CAPTCHA
