Publicity Information Form

Name of person completing this form

Email of person completing this form

Student Information

First Name

Last Name

Middle Initial

Class Year

Gender *

	Male
	Female

Street Address (Home)

City

State

ZIP

High School

High School City & State

High School Grad Year

Susquehanna Major(s)

Susquehanna Minor(s)

Future plans

Memberships and offices in clubs and organizations

Awards and honors

Varsity sports

Parent Information

Marital Status

Information of Father

Title

Name

Street Address (if different than home address listed above)

Please indicate if deceased.

Information of Mother

Title

Name

Street Address (if different than home address listed above)

Please indicate if deceased.

Publicity Information

How should parents names appear in the newspaper release? (i.e, Bob and Sue Smith; Mr. and Mrs. Bob Smith, Bob Smith and the late Jane Smith; Bob Smith and Sue Jones)

Please list newspapers in your home area. Include the full name of the paper and city and state in which it is published.

Newspaper #1

Newspaper #2

Publicity Information Form

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