Permission to Distribute Flyer Form

Please complete and return this form and one copy of distribution materials to Community Programs.

Fax: 641-684-6522
Phone: 641-684-6597/ ext. 66104
Email: roberta.davenport@ottumwasschools.com

Permission is Hereby Granted to:
Name: Name: * First Last
Telephone: Telephone: - ### - ### ####
Email: *
Fax: Fax: - ### - ### ####
Representing:
To: *

To: Post Distribute
Materials in the Ottumwa Community School District as follows:
Target Audience:
Students *

Students K 1 2 3 4 5 6 7 8 9 10 11 12
Building(s) *

Building(s) Douma Eisenhower Horace Mann James Liberty Wilson Evans OHS
Specific description of materials and their purpose (ex: distribute hike flyers to Grade K-6): *
The above mentioned materials must be pre-counted by classroom before distribution to schools. Please include and additional 10-15 copies, as attendance numbers change frequently. Once approved, a student count sheet will be sent for your use.

All items Must ContainDisclaimer:

" NOT AN OTTUMWA COMMUNITY SCHOOLS SPONSORED PROGRAM"

Date of Distribution Date of Distribution / MM / DD YYYY

Thursday only

Signed:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

Kim Hellige, Community Programs Director

Dated: Dated: / MM / DD YYYY

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Permission to Distribute Flyer Form

Permission to Distribute Flyer Form

Permission is Hereby Granted to:

Materials in the Ottumwa Community School District as follows:

Target Audience: