ANTI-HAZING LAW, M.G.L. c. 269, §§ 17-19

To:     Secondary School Principal or Headmaster

On behalf of ______________________________________________________, I certify that the (name of student group, team, or organization)    ______________________________________________________, and its members, plebes,

(name of student group, team, or organization) pledges, or applicants for membership have received a copy of An Act Prohibiting the Practice ofHazing, M.G.L. c. 269, §§ 17-19; and that the _______________________________________________ (name of student group, team, or organization) understands and agrees to comply with the law. Date: __________________________________ Signed: __________________________________________________ (Designated Officer) __________________________________________________ (Printed Name) Faculty Advisor or Leader:____________________________________ (for school affiliated group, team, or organization only)

Date Received by Principal or Designee: ________________________________ C: School Files Central Office Files

Reviewed, no revisions 3/3/12

Reviewed, no revisions 10/4/16