Self-Reported Travel Request Form – Clarksville Academy

We are requesting families to please complete this form if they are:

Traveling to known domestic or international areas where COVID-19 warnings exist or have verified community transmissions
Taking a cruise
Hosting visitors who have traveled to these areas in the last three months

This information will help keep our community safe and aid us in better knowing where members of our community are planning to travel and any action the school may need to consider upon their return. If you plan to travel, please carefully check the CDC travel website and the State Department website to ensure a safe experience for your family.

Relationship to Clarksville Academy(Required)

Alumni

Current Parent

Parent of Alumni

Grandparent

Faculty/Staff

Other

First Name(Required)

Last Name(Required)

Organization Name

Street(Required)

City(Required)

State(Required)

Zip(Required)

Email(Required)

Phone(Required)

This gift is:

Name

Untitled

My / My spouse's employer will match this gift.

I prefer to remain anonymous.

Third Choice I would like more information on volunteering at Clarksville Academy.

I/We understand that this/these gift(s) will be recognized on the basis of both the date and level of this pledge commitment and that any recognition given for this/these gift(s) will be made in accordance with Clarksville Academy's donor recognition policies and procedures. I/We authorize Clarksville Academy to include this/these gift commitment(s) in its internal reports, published materials (including electronic), annual report(s) and/or public releases (by grouped giving level(s) and not by an actual donation amount). Kindly record/recognize this/these gift(s) in the following manor:(Required)

Preferred Publishing listing (i.e. Anonymous, Smith Family, etc.) signature(Required)

Current Date(Required)