Student Publicity Form

First Name :

Middle Initial :

Last Name :

Contact Email :

Maiden Name :

Home/Contact Address :

Address 2:

City:

State/Province:

Zip/Postal Code :

Country selector:

Undergraduate Institution Information:

Please include name, city/state, year of graduation and degree/major.

Graduate Institution Information:

Please include name, city/state, year of graduation, degree/major and city/state of practice.

Commencement Award(s) Received :

Activities you participated in while at Salus:

Please include clubs, sports, volunteer work, honor societies or any other relevant activity you'd like to include.

Parents' Name/Address:

Local Newspaper(s):

Please include names of newspapers where release should be sent and address.

Spouse's Full Name :

Personal Information:

Any additional personal/professional information to include.

Security code:

Enter security code:

If you wish to have your photo sent with the release, please email the photo in a jpeg format to communications@salus.edu and make sure you put YOUR FULL NAME in the body of the email.