Alaska Tobacco-Free School Policy

ALASKA TOBACCO-FREE SCHOOL POLICY

Gold Star Policy Signage Request Form

Please complete and return this form upon passage by the School Board of the AASB comprehensive tobacco-free school policy, OR when your policy is otherwise updated to meet the criteria for a Gold Star standard. When the complete form is received, along with a copy of the new policy, RurAL CAP will mail signage for district buildings. The signage is courtesy of the State of Alaska Tobacco Prevention and Control program and communicates tobacco-free schools.

Check or fill in:

District Name ______

Previous Policy Status from District Report, August 2012 ______(Incomplete, Tobacco-Free School, Bronze Star, Silver Star)

_____ Adopted AASB Comprehensive Tobacco-Free Policy -OR- _____ Revised existing policy to include missing elements to meet criteria for a Gold Star standard

______Date Policy was adopted or revised by School Board

Each School District may request up to 6 signs per district building: _____ Number of district buildings _____ Number of metal signs requested (12’’ x 18’’) _____ Number of window clings requested (13.5’’ x 5’’)

Mailing address for signage (physical address please, Fed Ex will not deliver to a PO box):

Street City Zip Code

Contact individual

Return completed form to Amy Gorn, RurAL CAP. Email: [email protected], Fax: (866) 389-8484 – ATTN: Amy (contact to confirm received), or Mail: RurAL CAP, c/o Amy Gorn * 731 E. 8th Ave. * Anchorage, AK 99501

Tobacco Free Signage Available

Metal Sign Window Clings