School Application Form

School District Name*

School Name*

Address*

Street Address Address Line 2 City ZIP / Postal Code

Facility Coordinator*

First Last

Program's Point of Contact

Facility Coordinator Phone #*

Facility Coordinator Cell Phone #*

Facility Coordinator Email*

Does the school contain any of the following*

Check all that apply

Original school construction date*

If unknown, type "unknown"

Where does your drinking water come from?*

Has your school tested for lead in drinking water in the past?*

If yes, when:

What percentage of students are in the Free & Reduced Lunch Program?*

What is the districts median household income?*

What is the combined number of students and staff in the school?*

How many drinking water fountains, classroom sinks used for drinking water, and food preparation sinks are located in the school?*

Lead Sampling Coordinator Name*

First Last

Individual who will be mailed supplies and conduct sampling

Lead Sampling Coordinator Job Title*

Lead Sampling Coordinator Mailing Address

Street Address Address Line 2 City ZIP / Postal Code

Address used to send sampling supplies

Lead Sampling Coordinator Telephone #*

Lead Sampling Coordinator Cell Phone #*

Lead Sampling Coordinator Email*

Do you wish for your school to be recognized for participating in the DEQ's Certified Lead Free Drinking Water Award Program?*

Consent*

I hereby acknowledge that I have read, understand, and agree to implement the EPA's 3Ts guidance document for establishing a Lead Testing Program.