Power Lunch Application

Personal Information
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Email
Phone
Gender
Date of Birth
MM slash DD slash YYYY
Work Information
Company Name
Address
Street Address Address Line 2 City State ZIP Code
Phone
Supervisor
References
Please provide two references (business and personal)
Name Phone
Mentoring Information
I am interested in reading at:
I would prefer to read to a:
Days available:
- Select All
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
If you heard about Power Lunch through a friend or colleague, please list their name:
Acceptance
Please 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.
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Name	Phone

Personal Information