Name of Grant Program: Innovation Schools Implementation Grant
Fund Code: 157
PART IV-INNOVATION SCHOOL AUTHORIZATION AND ASSURANCES FORM
Instructions: Please complete each of the fields along with required signature section below. Three original,
signed copies of this form must be submitted to:
Office of Charter Schools and School Redesign
Attn: Sheika Edmond
Massachusetts Department of Elementary and Secondary Education
75 Pleasant Street
Malden, MA 02148
District Name:
LEA Code:
Innovation School Name:
School Committee Approval of Innovation School
Date of
School
Committee
Vote
School Committee Authorization: The school committee has reviewed the innovation plan,
and a majority of the committee as fully constituted voted to authorize the establishment of
the Innovation School.
District Assurances
The district must ensure that state funds are used in accordance with the Innovation Schools
Implementation Grant RFP and ensure transparency and accountability, and report publicly on the use of
state funds. The district must ensure that the innovation school or academy is operated in accordance with
the approved Innovation School Plan.
Districts must participate in any program evaluation and monitoring activities associated with this grant.
Typed Name of Innovation School Lead Applicant:
Signature of Innovation School Lead Applicant:
Date:
Typed Name of Superintendent:
Signature of Superintendent:
Date:
Typed Name of School Committee Chair:
Signature of School Committee Chair:
Date: