Release Form

First Name Of Recipient

Last Name Of Recipient

E-mail address for follow-up questions

Name of Hometown or Community Newspaper(s)

Current Classification Freshman Sophomore Junior Senior Graduate

Expected Date of Graduation

Degree Sought B.A.A.S. B.A. B.B.A. B.F.A. B.M. B.S. M.A. M.F.A. M.Ed. M.S. M.M. Ed.D. Ph.D. M.B.A. M.L.S.

Major Minor

Extracurricular activities (honors, organizations, sports, etc.)

Award, Honor or News Event

Local Address:

Address Line 1

Address Line 2

City State Zip

Phone ( ) -

Permanent Address:

Address Line 1

Address Line 2

City State Zip

Phone ( ) -

Additional Comments or Information

Parent(s) or guardian(s) and their permanent address