<p> ALASKA TOBACCO-FREE SCHOOL POLICY</p><p>Gold Star Policy Signage Request Form</p><p>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.</p><p>Check or fill in:</p><p>District Name ______</p><p>Previous Policy Status from District Report, August 2012 ______(Incomplete, Tobacco-Free School, Bronze Star, Silver Star)</p><p>_____ Adopted AASB Comprehensive Tobacco-Free Policy -OR- _____ Revised existing policy to include missing elements to meet criteria for a Gold Star standard</p><p>______Date Policy was adopted or revised by School Board</p><p>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’’)</p><p>Mailing address for signage (physical address please, Fed Ex will not deliver to a PO box):</p><p>Street City Zip Code</p><p>Contact individual</p><p>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</p><p>Tobacco Free Signage Available</p><p>Metal Sign Window Clings</p>