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For official copies of board policies and procedures please contact the superintendent's office at (253) 583-5190 or email

PDF version of Form 4060-F1

Form 4060-F1

Request to Distribute Material

Please send completed forms to Ben Miller ( in the community relations department.

Contact the Community Relations Department
Phone: (253) 583-5040 · (253) 583-5048

Date submitted: Distribution Date: Start End

Organization Name:

Organization Name on Nonprofit Document, if different:

Address: City: State: Zip

Person making request:

Phone: Cell: Fax:


EIN # / Nonprofit # Organization website :

  1. The following disclaimer must be included on information to be posted:

    Clover Park School District does not sponsor this event/activity/offer and assumes no responsibility for it. In consideration for the privilege to distribute these materials, Clover Park School District shall be held harmless from any cause of action filed in any court or administrative tribunal arising out of the distribution of these materials, including all costs, attorney’s fees and judgments or awards.

    Spanish version:

    El distrito no patrocina este evento, actividad u oferta y no asume responsabilidad alguna que pueda derivar de estos. En consideración del privilegio de distribuir estos materiales, se mantendrá indemne al Distrito Escolar Clover Park de cualquier acción judicial que se presente ante cualquier corte o tribunal administrativo con motivo de la distribución de estos materiales, incluidas todas las costas, los honorarios de abogados y las sentencias o laudos arbitrales.


  2. Organizations wishing to distribute information are encouraged to submit requests two weeks prior to an event, registration, etc.
  3. Submit a copy of your non-profit status - Internal Revenue Status 501(c)(3).
  4. Please indicate at which school(s) you would like your material posted. Ten copies of the material to be distributed must be printed and given to each selected school.

    It is the responsibility of each organization making the request to print and distribute the copies. A copy of this completed form (with approval) must be presented or sent with materials to each site. An enrollment count for district schools is available upon request.

    Lakewood’s Promise may distribute printed copies of its What’s Up in Lakewood publication to all district schools. This is the only organization that has been given permission for this distribution.


    Select individual schools(select individual schools if not sending to all schools):

    Secondary Schools:


    Elementary Schools:

* Custer, Dower, Four Heroes, Tillicum and Tyee Park Elementary Schools require distribution of printed materials in addition to an electronic version.



Authorization Date:

Approved for distribution with principal's permission:

Please send completed forms to Ben Miller ( in the community relations department.