State what you want to gain from the Safe Guard Program.

Honestly state that you understand the meaning of the objectives.

Ask for clarification where questions arise.

1. I, _____________________(safe guard) have read the weekly assignment packets for an over view of the program.

Yes_____________ No ______________

2. I hope to gain the following from the Safe Guard Program. (Use extra paper if needed and attach)

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Safe Guard Signature: ___________________________Date:______________