Student Media Release Form

If you have something to tell, either about someone you know or yourself, and you think it is news-worthy, please let us know! Just fill out the following form to the best of your knowledge. We will use the information that you provide to write a press release, and submit the news of your accomplishment or award to your hometown newspaper. We may also use the information for our online mediacenter news releases, and/or the Tartan (Belhaven's alumni and friends publication). If you would like a photo (.jpg format, please) to accompany your release, be sure to either send it via email, or drop it by our office or in the campus mail. pr@belhaven.edu/ Fitzhugh 100 / Box 264 We look forward to hearing from you!

(* indicates required information)

First Name *
Last Name *
Current School Year
Award received (be specific):
Home State/province:
Hometown paper & City (1):
Hometown paper & City (2):
Your E-Mail:
Your current phone number:
Your major:

Please provide your father's contact information (or stepfather's, if applicable):
First Name, Last Name:
Address:
City - State/Province:
Zip/Postal Code
Home Phone:

Please provide your mother's contact information (or stepmother's, if applicable):
First Name, Last Name:
Address:
City - State/Province:
Zip/Postal Code
Home Phone
Please provide your spouse's name, if applicable:

Please list any clubs, organizations, athletic teams, or councils that you are affiliated with:

Please list any other awards or honors that you have received:

What do you plan to do after graduation?

Please provide any other information that you would like to be included on your press release:

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