Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

How far are you willing to travel? *

15 Minutes

30 Minutes

45 Minutes

45 Plus Minutes

Not Able to Travel

I give permission for my references to be contacted via phone or email. *

Please provide 3 professional references that have known you for 3 or more years below. Provide a name, email, and phone for each reference. Family references are not accepted.

I agree

Reference #1 *

First Name

Last Name

Reference #1 *

Phone

(###)

###

####

Reference #2 *

First Name

Last Name

Reference #2 *

Phone

(###)

###

####

Reference #3 *

First Name

Last Name

Reference #3 *

Phone

(###)

###

####

I agree to submit my resume following my electronic signature and submission of this form. *

Please email your resume to grassrootshomeschool@gmail.com. Place RESUME and YOUR NAME in the subject line of your email.

I agree

Vexxitny and Grassroots Homeschool were created for organizational and networking purposes only. Submitter agrees to indemnify and hold Vexxitny and Grassroots Homeschool, and their respective officers, agents, representatives, and officials harmless from any and all loss, claim, actions, costs, or liability associated with its use of the network and related activities. Networks created from data collected are not sold to any third party. *

BY TYPING MY NAME IN THE BOX BELOW, I AM ELECTRONICALLY SIGNING THIS SUBMISSION. I UNDERSTAND AND AGREE FULLY TO ANY AND ALL CLAUSES IN THIS SUBMISSION.

First Name

Last Name