Help Us To Know You

Submission of this form gives the Geneva College Public Relations Department permission to use the above information for publicity purposes.

First Name:
Preferred Name:
Last Name:
Male	Female
Address:
City:
State:
Zip:
Home Phone:
Birth date (month/day/year)	/ /

High School Information:
High School Name:
City:
State:
High School Graduation Year:

Present College Class Status:
Freshman Sophomore	Junior Senior

Hometown Newspaper:
Name of newspaper:
City:
State:

Denomination:

Please list all Geneva College relatives (name, class year, relationship to you):

Please list all siblings (name, date of birth, last school attended and graduation year):

Father's Information:
Name:
Preferred Name:
Home Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
E-mail address:
	Home Work
Profession/Occupation:
Position/Title:
Company:
Company Address:
Board Memberships:
Colleges attended (include degrees and years):
Graduate schools attended (include degrees and years):

Mother's Information:
Name:
Preferred Name:
Home Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
E-mail address:
	Home Work
Profession/Occupation:
Position/Title:
Company:
Company Address:
Board Memberships:
Colleges attended (include degrees and years):
Graduate schools attended (include degrees and years):

I hereby give the Geneva College Public Relations Department permission to use the above information for publicity purposes. Please sign this form by typing your name and typing the date in the spaces provided below. *Your signature validates this form and indicates that you have completed the information and that the information is true.*
Student Signature
Date: