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Franklin Local School District

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<strong>Franklin</strong> <strong>Local</strong> Community <strong>School</strong><br />

76 West Athens Road<br />

Roseville, Ohio 43777<br />

Phone 740-697-7317, Ext. 3112<br />

David N. Branch<br />

Superintendent<br />

Sharon McDermott Christopher K. Miller, CPA Frank Van Kirk<br />

Director Treasurer Principal<br />

Provider Selection Form<br />

Please print:<br />

Student Name: ________________________________________________<br />

Home Address: _______________________________________________<br />

Grade Level: _____________<br />

Phone: __________________<br />

_______________________________________________<br />

Please write the name of the provider you want your child to receive tutoring from for the 2010-2011 school year:<br />

__________________________________________________________________________________________<br />

Please make your selection and return by September 1, 2010. Thank you.<br />

Send to:<br />

Sharon McDermott<br />

<strong>Franklin</strong> <strong>Local</strong> <strong>School</strong> <strong>District</strong><br />

360 Cedar Street, PO Box 428<br />

Duncan Falls, OH 43734<br />

Striving for Excellence<br />

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