Name of Grant Program: Innovation Schools Fellowship Grant
Fund Code: 159
PART V – Innovation Schools Fellowship Grant Submission Assurances Form
This assurance form provides the Massachusetts Department of Elementary and Secondary Education and the
Massachusetts Executive Office of Education with the confidence that all appropriate parties have been apprised
of this grant submission. Sign off by the school committee representative and teacher union president does not
signify endorsement and/or approval of grant application.
Instructions: Please complete one Assurance Form for each Fellowship application.
District Name:
Fellow Assurances
The proposed Innovation Schools Fellow is aware of this grant submission, participated in its
preparation, and is fully aware of the expectations set forth by the Massachusetts Department of
Elementary and Secondary Education and Massachusetts Executive Office of Education.
District Assurances
The district must ensure that state funds are used in accordance with the Innovation Schools
Fellowship Grant RFP and ensure transparency and accountability, and report publicly on the use
of state funds. The district must also ensure that the all state funds used to must be used to solely
support the Fellow’s in-depth, yearlong innovation school development process.
The district must participate in any program evaluation and monitoring activities associated
with this grant.
Typed Name of Proposed Fellow:
Signature of Proposed Fellow:
Date:
Typed Name of Superintendent:
Signature of Superintendent:
Date:
Typed Name of School Committee Representative:
Signature of School Committee Representative:
Date:
Typed Name of Teacher Union President:
Signature of Teacher Union President:
Date:
As noted above, sign off by the school committee representative and teacher union president solely signifies
that they have been apprised of the district’s grant submission, and does not signify endorsement.