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MQA Certificate of Individual Request for Loan of Textbooks and Instructional Materials/Equipment

Dear Parent or Guardian:

State legislation authorizes the loan of textbooks, instructional materials, and equipment by the Secretary of Education to Pennsylvania children enrolled in kindergarten through grade 12 in nonpublic schools. Our school annually submits requests for the specific textbooks, materials, and equipment to be loaned to your child(ren).

It is required, however, that a parent of each child attending the nonpublic school individually requests a loan of textbooks, instructional materials, and equipment.  Below is the individual request form. Please sign the form, date it, and return it to school immediately.

Thank you for your continued assistance and cooperation.

Very truly yours,
Cathy Collett
Principal

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CERTIFICATE OF INDIVIDUAL REQUEST FOR LOAN OF TEXTBOOKS AND INSTRUCTIONAL MATERIALS/EQUIPMENT

I hereby request the loan of textbooks and instructional materials/equipment in accordance with the Pennsylvania School Code of 1949 for my child(ren) attending Mary Queen of Apostles School.

This program is available only to Pennsylvania residents.
(This form is to remain on file at the school.)

First Parent/Guardian's Name

First Name*

Last Name*
First Parent/Guardian's Date of Birth*
I certify that I am 18 years of age or older
First Parent/Guardian's Signature*
Second Parent/Guardian's Name

First Name*

Last Name*
Second Parent/Guardian's Date of Birth*
Third Parent/Guardian's Name

First Name*

Last Name*
Third Parent/Guardian's Date of Birth*
Fourth Parent/Guardian's Name

First Name*

Last Name*
Fourth Parent/Guardian's Date of Birth*
Fifth Parent/Guardian's Name

First Name*

Last Name*
Fifth Parent/Guardian's Date of Birth*
Sixth Parent/Guardian's Name

First Name*

Last Name*
Sixth Parent/Guardian's Date of Birth*
Seventh Parent/Guardian's Name

First Name*

Last Name*
Seventh Parent/Guardian's Date of Birth*
Eighth Parent/Guardian's Name

First Name*

Last Name*
Eighth Parent/Guardian's Date of Birth*
Ninth Parent/Guardian's Name

First Name*

Last Name*
Ninth Parent/Guardian's Date of Birth*
Tenth Parent/Guardian's Name

First Name*

Last Name*
Tenth Parent/Guardian's Date of Birth*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Student Information

Student's Full Name (First Middle Last) *
Please select the student's grade level.*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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