ALASKA TECHNICAL CENTER 2020 - 2021 DORMITORY HANDBOOK - Northwest Arctic Borough ...

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ALASKA TECHNICAL CENTER 2020 - 2021 DORMITORY HANDBOOK - Northwest Arctic Borough ...
ALASKA TECHNICAL CENTER

       2020 – 2021
   DORMITORY HANDBOOK
ALASKA TECHNICAL CENTER 2020 - 2021 DORMITORY HANDBOOK - Northwest Arctic Borough ...
Alaska Technical Center
Dormitory Handbook

Table of Contents

General Information ..................................................................................................................................................... 4
   Dormitory Staffing ..................................................................................................................................................... 4
   Room Assignments .................................................................................................................................................... 4
      Key Assignments .................................................................................................................................................. 4
      Lockouts ................................................................................................................................................................ 4
      Check-In and Out Procedures ............................................................................................................................... 4
   Openings and Closures .............................................................................................................................................. 5
   Residence Meetings ................................................................................................................................................... 5
   Mail ............................................................................................................................................................................ 5
   Phone.......................................................................................................................................................................... 5
Dormitory Amenities .................................................................................................................................................... 5
   Laundry ...................................................................................................................................................................... 5
   Computer Laboratory ................................................................................................................................................. 6
      Network Etiquette and Privacy ..........................................................................................................................6/7
   Recreation Room ....................................................................................................................................................... 7
Housekeeping and Maintenance .................................................................................................................................. 7
   General Housekeeping ............................................................................................................................................... 8
   Weekly Linen Exchange ............................................................................................................................................ 8
   Maintenance Work Orders ......................................................................................................................................... 8
   Garbage Disposal ....................................................................................................................................................... 8
Visitor Guidelines ......................................................................................................................................................... 8
   Quiet Hours ............................................................................................................................................................8//9
Safety and Security ..................................................................................................................................................... 10
   Sick or Injured Resident........................................................................................................................................... 10
   Incident Reporting ................................................................................................................................................... 11
   Safety Inspections .................................................................................................................................................... 11
   Criminal Behavior .................................................................................................................................................... 11
      Alcohol and Illegal Drugs ................................................................................................................................... 12
      Weapons, Firearms and Ammunition ................................................................................................................. 12
      Smoking and Crewing Tobacco Products ........................................................................................................... 12
Corrective Action ........................................................................................................................................................ 13
      Suspension or Eviction from the Dormitory .................................................................................................. 13/14
ATC Statement of Non-Discrimination .................................................................................................................... 15
Appendix I ................................................................................................................................................................... 16
   ATC Staff Directory ................................................................................................................................................ 16
   Fire Escape Plan ....................................................................................................................................................... 17
  ATC School Calendar ............................................................................................................................................... 18
   ATC Forms .............................................................................................................................................................. 19
      Incident Report .................................................................................................................................................... 19
      ATC Dormitory Contract .................................................................................................................................... 20

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ALASKA TECHNICAL CENTER 2020 - 2021 DORMITORY HANDBOOK - Northwest Arctic Borough ...
Alaska Technical Center
Dormitory Handbook

Alaska Technical Center (ATC) strives to ensure that all trainees receive quality training in a
safe environment; this also extends to the residents in the dormitory. We ask for your
cooperation to help us achieve this goal by observing the rules. This helps ensure safety, comfort,
and a pleasant residence for all. Failure to adhere to the rules can result in serious consequences
and/or termination from ATC.

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Alaska Technical Center
Dormitory Handbook

General Information
Dormitory Staffing
A dormitory attendant is on duty 24-hours a day throughout the school year except during the
weekday depending on special circumstances and when trainees are in class from 8:30 am to
4:30 pm.

Room Assignments
A specific roommate may be requested; however, it cannot be guaranteed your request will be
granted . It will be considered when making room assignments.

Key Assignments
The dormitory attendant will check-in you in and assign a room key. It is your responsibility to
have your key to ensure access and security to your room . ATC is not responsible for lost or
stolen items.

If you lose your key, please notify the dormitory attendant on-duty as soon as possible. A
replacement will be requested and a charge fee of $40.00 must be paid prior to receiving a new
key.

Lockouts
As responsible individuals and residents, it is asked that the residents keep their keys with them
at all times. In the event that you locked out, please report to the Dormitory Attendant on duty.

Check-In and Out Procedures
Upon arrival, please check-in with the dormitory attendant on-duty who will review general rules
with you and have you fill out the necessary paperwork and then assign your room key.

Upon check-out of the dormitory please ensure that the following is done:

       □ Return key to Dorm Attendant on duty
       □ Return Linen and towels
       □ Vacuum and clean room
       □ Empty trash and wash out trash can
       □ Remove all wall hangings, pins, hooks, etc.
       □ Report any damages and the need for repair or replacement to Dorm Attendant

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  Dormitory Handbook

Openings and Closures
See the school calendar for open and closure dates.

ATC will have three school breaks: Thanksgiving break (due to COVID19 this year students will
stay on campus and not be able to leave for Thanksgiving Break): Christmas break: and Spring
break. The dormitory will be closed during these school breaks. No students are allowed in
the dorms during the breaks.

Residence Meetings
ATC staff may from time to time request to have a meeting with residents. Advance notice of
the date, time and location of the residence meetings will be provided.

Mail
Dormitory residents may receive mail while they are at the Alaska Technical Center. Mail can be
addressed as follows:
          Trainee Name
          c/o Alaska Technical Center
          P.O. Box 51
          Kotzebue, Alaska 99752

  The physical address for the dormitory is 839 Fourth Street; Kotzebue, AK 99752.

  Phone
  A phone is available for dormitory residents and is located next to the recreation room. The phone
  number is (907) 442-3142.

                                    Dormitory Amenities
  Laundry
  The dormitory is equipped with a laundry room with washers and dryers. Residents will have
  access to the laundry room as follows:

          Monday:                       5:00 pm – 10:00 pm        Due to COVID19 laundry times
          Tuesday:                      Closed for staff use      must be scheduled with the
          Wednesday and Friday:         5:00 pm – 10:00 pm        Dorm attendant on duty to
          Saturday and Ssunday:         9:00 am – 10:00 pm        ensure physical distancing.

  The laundry room will be closed and locked during all other times. Please note that washers and
  dryers are for dormitory residents and dormitory use only.

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Dormitory Handbook

Computer
Residents will be assigned a laptop computer for training curriculum use ONLY. The computer
internet access and various program applications to assist them with their academics.

Beverages are prohibited around the laptop computers – The laptop computer is offered as
a privilege and residents are expected be respectful of other residents who may be doing
homework.

Network Etiquette and Privacy
You are expected to abide by the generally accepted rules of network etiquette. These rules
include but are not limited to:

   1. Be Polite: never send, or encourage others to send, inappropriate or abusive messages;
   2. Use appropriate language: you are a representative of your school on a public system.
      Never swear, use vulgarities, or any other inappropriate language;
   3. Privacy: do not reveal the addresses or phone numbers of friends or colleagues without
      written permission;

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   4. Disruptions: do not use the network in any way that would disrupt the use of the network
      by others. Do no damage hardware or software;
   5. Representations: do not originate anonymous messages or represent a message to have
      been authorized by another. All correspondence should be clearly identifiable as to its
      originator. Any transmission or use, which has the purpose or effect of promoting hatred
      or harassment, is prohibited.

If you identify a security problem in the building or network, notify the dormitory attendant at
once. Never demonstrate a problem to other users. Never use another individual’s account. Never
tell anyone your password. Any user identified as a security risk will be denied access to the
network, and may be liable for disciplinary action or prosecution.

Recreation Room (During the 14 day quarantine period the Rec Room is closed.)
The recreation room is closed 10:00 pm Sunday – Thursday and 10:00 pm Friday and Saturday.
The Recreation Room will be closed to residents during training hours.

No foul language, loud music and any disputes will be tolerated. Such behavior will be grounds
for removal from the recreation room.

                           Housekeeping and Maintenance
General Housekeeping
ATC staff is responsible for providing clean and sanitary surroundings for residents and maintains
all common areas. Residents are responsible for the care and cleanliness of their own room. The
Dormitory Attendant on-duty will make available vacuum cleaners and garbage bags during
reasonable hours.

The Dormitory Attendant will conduct weekly inspections on Tuesdays with an optional
room inspection on Saturdays. All residents will cooperate by cleaning their room, emptying
their garbage, making their bed, vacuuming their room and showing their room key. Any
unlocked rooms will be locked.

The Dormitory Attendant will knock on the door and identify themselves as such.

Any resident not complying          with    housekeeping    rules   will   be   referred   to   the
Recruiter/Administrator.

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Dormitory Handbook

Weekly Linen Exchange
To ensure a safe and sanitary environment for all residents, there is a mandatory linen change every
Tuesday. Residents are required to wash all their white linens assigned to their rooms (sheets,
pillow cases, and mattress covers)Those who have their own linen are still required to wash
weekly. (Please see the Dorm attendant to schedule times to wash laundry to ensure physical
distancing.)

Maintenance Work Orders
ATC staff is responsible for insuring necessary repairs are made to the building. In-house staff
handles plumbing, electrical and general carpentry. In emergency situations, repairs are made as
soon as possible, although some situations may take longer.

Damages or items in need of repair are to be reported to the Dormitory Attendant on-duty
immediately. A Maintenance Work Order Form must be completed to describe the type of
problem and the location of the problem. If the problem is not attended to, please inquire at the
ATC Administration for further assistance.

Garbage Disposal
Place all garbage in the dumpster at the west end of the dormitory.

Visitor Guidelines
Due to COVID19 the ATC Adult Dormitory is only available for Residents residing in the
dormitory during their training. BUIDLING IS CLOSED TO VISITORS. The Dormitory staff
will enforce the no visitors rule established by ATC Administration.

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Restricted Operations essential activities only.
This stage applies to specific housing areas, training programs, or the entire school.

Allowed Operations and Activities are:

•       ACCESS: All buildings locked. Access for visitors to campus facilities is restricted to dormitory
residents only and essential ATC Dormitory staff.
•       SERVICES: All services unavailable in person: remote appointments available
•       INSTRUCTIONAL: Only training that can be conducted remotely will be provided until further
notice.
•       MEAL SERVICES: Cafeteria services available are ‘To Go’ only. (Meals may be taken to the
dormitory)
•       ON-CAMPUS HOUSING: Congregate housing is open at 50% maximum capacity (20 individuals
maximum and residential rooms are to be one individual per room only). Residents are required to hunker
down as much as possible in the residential dormitory and follow all local COVID19 mandates. All indoor
recreation activities at the dormitory are to advise residents to wear a mask, maintain 6 feet physical
distancing and continue to wash your hands or use hands sanitizer.
•       WORKPLACE: Staff will provide remote instruction when in quarantine or there is significant
increase in COVID19 numbers in Kotzebue.
•       STUDENT TRANSPORTATION: There are no transportation services available with ATC.
Emergency Medical Services will be requested by contacting 911 or Maniilaq Health Center for Emergency
services only.

Protective Measures are:

•       All publicly ordered health mandates shall be followed - City of Kotzebue, Northwest Arctic
Borough and the Northwest Arctic Borough School District.
•       Students residing in residential dormitory housing must agree to quarantine in housing and report
symptoms immediately to staff
•       COVID testing of staff and students will occur when and where appropriate
•       Use of masks is required inside all ATC facilities and vehicles
•       Social Distancing is required on campus – group activities are not permitted.
•       Signage requiring personal hygiene (handwashing, coughing into sleeve) and social distancing and
bubble-shrinking (this means only limited contact with others not in your immediate physical household,
example is other dormitory residents and not out in the community)
•       Sanitization of common/shared areas and facilities at least once every hour while the dormitory is not
in quiet hours (10pm to 7am) per day if students remain in housing areas Operations/protective measures
will be re- evaluated by Administration at least every 24 hours
•       Student Housing Curfew – 10 PM-6 AM every day. Residents are strongly encouraged to minimize
time in public spaces or with groups other than their training cohort
•       Students who travel outside of Kotzebue may not return to campus until receiving a negative
COVID19 test result. Students traveling at any time while enrolled in their training program are responsible
to find alternate housing (room & board) until a negative COVID19 test result is provided to administration.

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Alaska Technical Center
    Dormitory Handbook

    Quiet Hours
    The dormitory is a living and learning environment that is shared by other residents. In maintaining
    respect for neighbors’ desire to sleep, study, etc. all residents are encouraged to keep the music
    and other noises to a minimum. Residents must conduct themselves in a manner that will not
    disturb others. Quiet hours are as follows: Due to COVID19 we are enforcing the Curfew times.

           Sunday through Thursday:        10:00 pm – 6:00 am
           Friday and Saturday:           10:00 pm – 6:00 am

    Safety and Security
    The following are general safety and security rules that residents must be familiar with:

•     All residents must become familiar with the location of fire extinguishers, fire alarm system,
      and emergency exits. FIRE EXITS ARE FOR EMERGENCIES ONLY
•     It is unlawful to tamper with the fire alarm system and equipment.
•     Cooking in rooms is prohibited due to the potential health and fire hazards.
•     Candles and incense are not allowed in the dormitory due to a fire hazard. Any incense or
      candles found in the dormitory will be confiscated.
•     No pets or animals are allowed in the dormitory.
•     All vehicles must be parked in the designated parking area.

    Sick or Injured Resident

    Any resident too sick or injured to come to class must seek medical care and obtain a
    Doctor’s slip to be in the dormitory during training hours.

    For any other reason residents must have the ATC Administration permission to be in the
    dormitory during training hours.

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    Incident Reporting
    The ATC Dormitory Attendants are responsible for enforcement of the rules outlined in the
    Dormitory Handbook and will notify ATC Administration of any unusual/disruptive incidents;
    Residents may also report any unusual/disruptive incidents which should be reported
    immediately to the Dormitory Attendant on-duty. Assistance cannot be provided unless the
    Dormitory Attendant’s notified.

    The only way problems are solved is providing the necessary facts surrounding an incident.
    Additionally, you will be called upon by staff to complete a written statement describing the
    incident. This involves the who, what, where, when, time, and general description of the
    incident. The Incident Report Form is located in Appendix 1 of this handbook.

    Safety Inspections
    ATC staff reserves the right to enter residents’ room without notice if staff believes that there is
    probable cause of a resident for the health and safety. If the Dorm Attendant suspects alcohol,
    illegal drugs or weapons, firearms and ammunition are on the premises they may enter without
    notice.

    Criminal Behavior
•     Assault on any resident, guest or staff is not be tolerated and may be grounds for immediate
      removal and possible suspension and/or eviction from the dormitory.
•     Vandalism of ATC, staff or trainee property is not to be tolerated and the violator may be
      prosecuted to the full extent of the law. If the vandalism involves destruction of property that
      threatens the health and safety of staff, trainees or guests, the violators may be terminated from
      their program and will be charged for the cost of repairs.
•     All criminal behavior may be referred for criminal prosecution, suspension and/or eviction from
      the dormitory, and/or termination from ATC programs.

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Alcohol and Illegal Drugs
ATC has a zero tolerance policy for possession, consumption or distribution of alcohol and illegal
drugs on all ATC property.
ATC has very strict policies regarding alcohol and illegal drugs for the following reasons:
1. State Law: Alaska State Law prohibits the use or storage of alcoholic beverages, marijuana,
   or other illegal drugs in and around state-controlled buildings and grounds. No alcohol or
   illegal drugs will be allowed on the premises of any training sites.

2. Learning: Trainees are at ATC for a short period of time to learn skills that lead to
   employment. Instructors teach by utilizing both classroom training and hands-on instruction.
   Trainees should be in excellent physical and mental condition for learning to occur.

3. Safety: Safety in the classroom, shop or training site is important. Trainees will be utilizing
   tools and equipment that requires total concentration. A trainee under the influence of alcohol
   or drugs may not use correct judgment and jeopardizes the safety of self and others.

If ATC staff suspects that alcohol or illegal drugs are on any ATC premises, then the Kotzebue
Police Department may be called. Failure to comply with ATC policy and/or community and state
law is cause for disciplinary action up to and including termination from the school.

Weapons, Firearms and Ammunition
The possession or use of weapons, firearms, ammunition, explosive or combustible materials,
pistols, revolvers, pellet guns, air guns, and/or injury-threatening weapons deemed by the ATC
Director to be deadly, are strictly prohibited. This includes, but is not limited to, daggers,
machetes, slingshots, switchblade knives, pocket knives with a blade of more than 2 ½ inches in
length, weapons commonly known as blackjacks, sand-clubs, billy-clubs, and metal knuckles.
Potentially dangerous items such as metal pipes, bars, razors with an unguarded edge, or kitchen
knives, will fall within this category of prohibited objects, if used for a purpose other than the
purpose for which it was intended, i.e. as a weapon or to instill fear in another.

Smoking and Chewing Tobacco Products
Smoking is prohibited in all ATC facilities. Smoking on ATC property is allowed only in areas
designated for smoking. All of these areas of outside of the school and dormitory building and at
least 50 feet away from entrances and exits. Please put cigarette remains in one of the approved
receptacles provided around the buildings. Trainees smoking in prohibited areas will be subject
to disciplinary action.

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Corrective Action
Suspension or Eviction from the Dormitory
Immediate eviction from the dormitory will occur if violence (assault) is involved. Residents
living at the dormitory and all trainees at ATC have a need for a comfort (safety) zone and this
includes the dormitory and school. Any resident assaulting other residents, trainees, staff or guests
will be permanently evicted from the dormitory.

If there is a serious Dormitory Rule violation, an Incident Report will be given to the ATC
Administrator and suspension will occur. In this case, suspension and/or eviction if warranted
will progress as outlined below:

   1. First Incident –               2-day suspension

   2. Second Incident –              7-day suspension

   3. Third Incident –             30-day suspension If alcohol or drugs are involved the
      violator must obtain screening from the Maniilaq Recovery Center and follow their
      recommendations. Residents must also sign a release so that MRC may provide ATC
      with updates of the treatment program.

   4. Fourth Incident –              Permanent eviction from the dormitory

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 Dormitory Handbook

 Re-Admittance for Dormitory Residence
 Trainees who have been evicted from the ATC Dormitory may request in writing for re- admittance
 after 30 days. The trainee must present information to the Director showing corrective measures
 taken including but not limited to:

     1. Alcohol and/or controlled substances assessment and subsequent substance abuse
        counseling appointments,
     2. Anger management training,
     3. Counseling sessions,
     4. Any other appropriate methods of self-improvement,
     5. A statement explaining why trainee should be considered for re-admittance into the
        dormitory, and
     6. Consent to continued probationary status.

 This may mean signing a release of information to the appropriate agency so that ATC can
 confirm any of the above.

 The Director will receive a recommendation from both the Dormitory Attendant and
 Recruiter/Administrator before a final decision is made.

 Types of violation include the following:
• Assault (sexual, fighting, or threats of violence)
• Minor consuming alcohol
• Use, storage or sale of alcohol and/or illegal drugs on the premises
• In dorm during class times without leave of application form, Doctor’s slip or permission from
   ATC Administrator
• Disorderly conduct
• Refusal to leave the building when asked by staff when under the influence of alcohol and/or
   illegal drugs
• Arguing or abusive language
• Sexual or other types of harassment
• Visitors in dormitory room
• Vandalism
• Damage to ATC, residents’ or guests’ property
• Possession of firearms or dangerous weapons
• Smoking in dormitory room on other ATC property
• Inappropriate clothing or lack thereof
• Failure to keep resident room/common area clean after use
• Disturbing other with loud noise, music, TV, etc.
• Cooking in dormitory room
• Spitting in Recreation/Common areas
• Violation of any State or local laws

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ATC Statement of Non-Discrimination

The Alaska Technical Center does not discriminate in employment, admissions, access to or
treatment in its programs, activities and services on the basis of race, color, age, sex, national
origin, veteran status, handicap or others as prescribed by applicable state and federal laws or
regulations, including Title IX of the Education Amendments of 1972, Section 504 of the
Rehabilitation Act of 1973 and E.O. 11246 as amended.

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 Dormitory Handbook

                           STAFF DIRECTORY

ATC Administration
                           Cheryl Edenshaw, Director
                           Vacant, Recruiter/Administrator
                           Georgianna Phillips,Registrar
                           Karen Uhl-Sours, Secretary

                            Alaska Adult Education (AAE)
 Faculty and Staff
                            Forest "Rose" Walker,Instructor

                            Construction Trades Technology
                            Michael Harrison,Instructor

                            HealthCare Occupations
                            Cindy Lincoln, Instructor

                            Process Technology
                            Vacant,Instructor

                            Culinary Arts
                            Alejandro Vargas, Instructor

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                                  ATC SCHOOL CALENDER
                                         2020-2021

Fall 2020 Term Classes Begin              September 30, 2020

Thanksgiving Holiday Break                November 26 & 27, 2020
*Students will stay on campus
during the Thanksgiving Break

Classes Resume                            November 30, 2020

Christmas Break                           December 18, 2020
Dorm Closes at 4:30 pm                    December 18, 2020

Spring 2021 Term Classes Begin             January 13, 2021
Dorm Reopens at 1:00 PM                   January 11, 2021

Spring                   Break            March 15 - 19, 2021

Dorm                     Closes           Friday March 12, 2021@ 4:30 pm

Dorm Reopens                              Sunday, March 21, 2021 @ 1:00 PM

Classes Resume                            March 22, 2021

ATC Graduation                            May 12, 2021 (TBD)

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Dormitory Handbook

                                 Alaska Technical Center
                                Incident Report

Trainee Name:

Others involved:

Dorm Attendant:

Date/Time:

Rule(s) violated listed in Trainee Handbook:

      Copy to Administration             Copy to Trainee File

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    Dormitory Handbook

    ATC Dormitory Contract

                       ATC Dormitory Residence Contract
                      CONDITIONS OF THE CONTRACT AND PAYMENT

    This is a binding agreement between the Alaska Technical Center (ATC) and the
    student signing this contract. This contract covers the entire academic year for which
    the student has contracted for training.

•     A student may move in one day prior to the first date of training, and move out the
      day of graduation/withdrawal/termination. Residence beyond these days will be at
      the discretion of the Administrator/Recruiter or the Director.
•     The student resident must pay his/her dormitory bill for the entire term the first day of
      training. Fall term is the period of time from the start of the student’s training program
      until the Christmas break. Spring term is the period of time from the end of Christmas
      break until the student’s graduation date or summer break, whichever comes first.
•     Failure to make timely payments may terminate the contract.
•     If the student chooses to move into the dorms after the term has begun, fees must
      be paid when the student moves in for charges starting the day they move in until
      the end of the term.
•     Students must move out of the dorms at the end of each term (Christmas and
      summer).
•     The student must notify a dormitory attendant and the Administrator/Recruiter if they
      intend to move out or in the dormitory after any break. This notification must be
      made in writing.
•     If a student moves from the dormitory at any time during the contract period, either by
      choice, eviction, withdrawal, or termination, the student forfeits payments made for
      the current dormitory term charges. Students who graduate early will be charged up
      to the date they move out of the dorms. Any payment in excess of charges will be
      refunded.
•     Students who have been awarded sufficient financial aid to cover tuition and room
      and board payments may delay full payment until financial aid disburses. All
      payments will be automatically deducted for the remaining balance once the
      financial aid disburses.
•     Students who do not meet requirements for their financial aid disbursement, due to
      not meeting Satisfactory Academic Progress requirements or any other reason, must
      make other payment arrangements for what is owed ATC.
•     Termination of this contract for extenuating circumstances must be addressed in
      writing to the Administrator/Recruiter and/or Director.

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                                 CONDITIONS OF RESIDENCE

•    Must maintain an active enrollment in an ATC career training program and maintain
     sufficient academic progress

•    Dorm rooms are assigned by the ATC dormitory staff; changes to room assignments
     must be approved by the Administrator/Recruiter

•    Each resident is responsible for keeping his/her residence clean and for preventing
     damage beyond reasonable wear to ATC property. Damage charges will be billed to
     the resident when damage occurs, or when the resident checks out. The resident will
     be responsible for the costs.

•    When checking out of the dormitory residents must ensure that their dormitory room
     is clean:
           ü Turn in your linens to the dormitory attendant on duty
           ü Empty trash can and make sure it is clean
           ü Ensure the room is dusted/vacuumed and generally clean
           ü Close and lock room windows
           ü Turn lights off
           ü Lock the room door
           ü Turn in your key to the dormitory attendant on duty

•    ATC will assume no responsibility for the loss or damage of personal property of
     residents.

•     The resident agrees to abide by all rules and regulations as printed in the ATC
      Dormitory Handbook. Specifically, alcohol and controlled substances are strictly
      prohibited from the dormitory, and all ATC facilities. Any student who is found in
      possession and/or under the influence of alcohol and/or controlled substances will
      be subject to disciplinary action up and including eviction from the dormitory with no
      refund of room and board for the term in which the eviction occurs. All other rules
      and regulations must be read and understood before the signing of this contract.

                Resident’s Printed Name

                Resident Signature                                            Date

                ATC Recruiter/Administrator                                    Date
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