Student Pledge Against Gun Violence

Fax Tally Sheet

Please print the following form, fill it out, and fax it to (507) 663-1207 or (507) 645-2893, or send information via email to [an error occurred while processing this directive].

OUR SCHOOL PARTICIPATED IN THE
STUDENT PLEDGE AGAINST GUN VIOLENCE!

Number of Students
who signed the Pledge:

_____________________________________________*
School Information:  

School Name:

_____________________________________________*

City:

_____________________________________________*
State: _____________________________________________*

School Phone:

_____________________________________________

Contact Person:  

First Name:

_____________________________________________

Last Name: _____________________________________________
Phone: _____________________________________________
Email: _____________________________________________
  * required for national reporting purposes

Please report your tally on October 20, 2004.
The total number of signed pledges can be seen at www.pledge.org.