Student Publicity Form

Student Publicity Form
West Virginia Wesleyan College
Submission Date
MonthDayYear
Date
Full Name
First NameMiddle NameLast Name
Gender
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
E-mail
Name of High School
High School Graduation Year
Hometown Newspaper(s)
I hereby authorize use of this information and/or any photos taken while at
Wesleyan by the Wesleyan Marketing and Communication and External
Relations Offices for news information, campus publications and press releases.
Should be Empty: