Academic Affairs

Students celebrating their graduation

News and Photo Release Form

Your Name:
Title: Mr. Ms.
First Name:
Middle:
Last Name:

Permanent Hometown Street Address

(where you grew up)

Street Address:
 
 
City:
State:
Zip/Postal Code:
Country:

Contact Info:

  (So that we may contact you if we have questions about your information.)

Phone:
Mobile/Cell:

At Clark
Are you a:
Your Major:
Your Academic Degree:
Date Awarded:
(or expected)		 (mm/dd/yyyy)

Previous Schooling
High School:
City/State:
Graduation:
(month/year of high school graduation)

Previous Degrees:

  (if applicable)

Degree:
Academic Institution:
Date Awarded: (mm/yyyy)


Degree:
Academic Institution:
Date Awarded: (mm/yyyy)

Parent/Guardian Information

    First Parent/Guardian
 
Name:
Relationship:
Address:
 
City:
State:
Zip:
Country:
 

    Additional Parent/Guardian Information
 
Name:
Relationship:
Address:
(if different from above)
 
City:
State:
Zip:
Country:

Hometown Newspapers
Enter the name of up to two hometown newspapers, their city, state and zip code: