PC-2042 Correspondence Match Enrollment Form

Correspondence Match Enrollment Form
Name
School
Address
City

State

ZIP

School phone

Home phone

Primary e-mail
Grade

Subject

Number of students

Signature

Date

May we quote you in our materials?

Yes

No

If you know a Volunteer with whom you would like to correspond, please indicate:
Name

Country of service

Geographic preference
Choose three areas and rank them
in order of preference. Your first
choice may not be available due to
geographic distribution of
Volunteers.

Africa
Mediterranean/Eastern Europe/Central Asia
Central/South America
East Asia/Pacific Islands
French Speaking
Spanish Speaking
No preference

Optional questions
Please enter A, B, C, or D from the
scale below to indicate the makeup of
your student body. By answering
these optional questions, you will
help World Wise Schools reach its
goal of bringing global education to a
diverse population.
A: Under 10%

B: 11%–25%

American Indian or
Alaska Native
Asian or Pacific Islander
Black (Not of Hispanic origin)
Hispanic
White (Not of Hispanic origin)
Other

C: 26%–50%

D: Over 50%

Please describe your
school:
(check all that apply)

Public
Private
Parochial
Home
Charter
Not a
school

Periodically, we receive requests for information from the media, Congress, returned Volunteer
groups, or educational institutions. May we release information about you (name, school, and school
address only) to these groups?
Yes
No

www.peacecorps.gov/wws/correspond
[email protected] (tel) 800.424.8580, ext. 1450 (fax)202.692.1421
The Peace Corps Act (22 USC § 2501 et seq.) authorizes this collection of information. It will be used to enroll educators in the Coverdell World Wise Schools Correspondence Match program for the purpose
of promoting a better understanding of other peoples and cultures in U.S. classrooms. Information provided will be recorded by the Peace Corps and, when permitted by the educator, may be shared with the
media, Congress, returned Volunteer groups, educational institutions, and other government agencies. Providing the information herein requested is voluntary. The Peace Corps may not conduct or sponsor, and
a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The time required to complete this information collection is estimated to average 10
minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments on this form to Peace Corps, Office of Domestic Programs, Coverdell World Wise Schools, 1111 20th Street, NW, Washington, DC 20526. OMB control number: 0420-0513. Continuous use form.
Feel free to make copies of this form to share with your colleagues.

PC-2042 (Rev 07/2006) (Other versions of this form are obsolete.)

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Peace Corps
Paul D. Coverdell / Peace Corps Headquarters
1111 20th St. N.W. 2nd Fl
Washington, DC 20526-0002
_________________________________
OFFICIAL BUSINESS
PENALTY FOR PRIVATE USE $300

NO POSTAGE
NECESSARY
IF MAILED
IN THE
UNITED STATES

BUSINESS REPLY MAIL

FIRST-CLASS MAIL

PERMIT NO. 13741

WASHINGTON, DC

POSTAGE WILL BE PAID BY PEACE CORPS

PEACE CORPS
PAUL D. COVERDELL / PEACE CORPS HEADQUARTERS
CORRESPONDENCE MATCH PROGRAM
1111 20TH ST NW 2ND FLOOR
WASHINGTON, DC 20077-5400

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