Student Publicity Form

* - denotes a required field

Newspaper Information

Newspaper #1 Name:*
Address: (if known)

Newspaper #2 (optional) Name:
Address: (if known)

Student Information Full Name:*
Email: (post graduation)
Gender: * Male Female
University Address:

Academics, Activities & Awards at Millersville University Major:*
Degree:*
Activities:
Leadership Positions:
Awards/Scholarships/
Honors:

Hometown Information Phone:*
Street Address:*

City:*

State:*

Zip:*

County:*

Parent/Guardian Information Name(s):
Address(es):
Phone:
Occupation(s):
Employer(s):
Colleges/Universities: (include class year)

Special Information:

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