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Publicity and Promotional Consent Form

First Name
Preferred Name
Middle Name
Male Female
Birth date
(month/day/year)
//
Email
Student's cell
Parent's cell
High School Information:
Present College Class Status:


I hereby give the Geneva College Public Relations Department permission to use my name or likeness (including but not limited to a dean’s list announcement as a hometowner news announcement) 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:

Institutional Advancment Information

Father's Information:
E-mail address
Home
Profession/Occupation
Position/Title
Company
Company Address
Board Memberships
Colleges attended (include degrees and years):
Mother's Information:
Home
Colleges attended (include degrees and years):