MOU Request

Name of Agency*

Description of agency or organization*

Agency Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Program Name*

DME Connection*

Program Director Name*

First Last

Program Director Email*

Program Director Phone Number*

School Name(s)*

In which school(s) would this program be placed? Click the (+) button to add multiple schools.

What type of on-site space does the program require?*

(ie: classroom, gym, cafe)

When would the program take place?*

Select all that apply. After School programs serving students that end later than 6:00 pm are subject to a fee.

Do you need access to the building on weekends?*

programs that take place on the weekends will incur a fee

Program Start Time*

: HH

MM

Program End Time*

: HH

MM

Which days will the program take place?*

Program Duration*

Please enter the duration of the program. For example: 8 weeks, or January to June.

Grades Served*

Select all that apply

Number of Students Served*

Brief description of program*

HPS Responsibilities

Agency Responsibilities

Questions or Comments

A member of our team will be in contact with you within one week of submission. Please note it can take up to four weeks for an MOU to be executed.

CONTACT