N-O-T Evaluation Package Check List (please assemble in the order given)

1. Facilitator Forms à Yellow (one set of forms per clinic, stapled please)

q Participant List

q Facilitator Process

q Cost Tracking

2. Participant Forms (one set of forms per teen, stapled please)

q Session 1 forms à Orange

1) N-O-T About Me 1

q Session 10 forms à Green

1) N-O-T About Me 2

2) Tell Us What You Think

$ 250 Stipend Request

Upon completion of Session 10 please fill out completely and mail with evaluation materials to the

address below.

Facilitators Name: ____________________________________________________________

School: ____________________________________________________________________

Address where you want check mailed to: _________________________________________

City: ________________________________ State: _____________ Zip: ________________

County: ________________________________ Phone: ______________________________

Date Evaluations Mailed: __________________Social Security Number: __________________

Email Address: ___________________________________________

Signature: _______________________________________________

We have a new requirement for fiscal year 2005. We are required to have W9 forms on anyone we pay any

money to. Effective July 1, 2005. This is the link where you can down load the form please fill it out and send

to me with the stipend request http://www.irs.gov/pub/irs-pdf/fw9.pdf If we don't have this form on file, I

won't be able to process your check. Sorry

Send package to:

Tony Richards, Program Manager

American Lung Association of WV

415 Dickinson Street

Charleston, WV 25339-3980

$250.00