Welcome!  Please complete and submit by Friday, April 8, 2016.  Good luck.
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Name *

 
High School

 
FSU email/FSUID

 
Home Address

 
City/State/Zip

 
Phone

 
Email

 
GPA (Weighted)

 
GPA (Non-Weighted)

 
ACT and Date Taken

 
SAT and Date Taken

 
List Scholastic/Academic or other Achievement awards recieved during high school:

 
Scholarship Release of Information Form  
The purpose of the Family Educational Rights and Privacy Act of 1974 and the Florida Student Privacy Act is to protect the privacy of individual students by placing certain restrictions on the disclosure of information contained in a student’s university records as defined in those enactments.  I understand that in order for the University to honor a verbal or written request for information by anyone other than the individual student and certain others authorized by statute, both Florida Statute 1002.22(3)(d) and the federal “Buckley Amendment,” 20 U.S.C. 1232g, permit the release of such records only upon receipt of an appropriate signed authorization from the student.   This release of information allows Florida State University to share information with the FSU Alumni Association for the purpose of identifying students who may be eligible for scholarships. 
By typing my name below, I  give my FULL consent to THE FLORIDA STATE UNIVERSITY to release my student personally identifiable records and reports and education records, including, but not limited to, grade point average, age, financial need, enrollment and attendance records, address and telephone to:  FSU Alumni Association I understand that it will be necessary to send a written request to revoke this authorization. Any information release pursuant hereto is released subject to the confidentiality provisions of appropriate state and federal laws and regulations, which prohibit any further disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise permitted by such law and regulations.

By typing in my name below I give full consent to the above.
NAME:
FSUID:
DATE:


 
Standard Release    
For any and all purposes, I hereby grant to the Seminole Club of Volusia and Flagler Counties and The Florida State University Alumni Association and its employees, agents, and assigns, the right to photograph or visually record me and use my picture, silhouette, and other reproductions of my physical likeness (as the same may appear in any still camera photograph and/or motion picture film or videotape recording), in and in connection with the development of any media materials and exhibition thereof; also in the advertising and/or publicizing of any such media. I further give the Seminole Club of Volusia and Flagler Counties and The Florida State University Alumni Association, and any of its employees, agents, and assigns, the right to produce and utilize in any manner whatsoever recordings of my voice for any and all media purposes.   I hereby certify and represent that I have read the foregoing and fully understand the meaning and effect thereof and, intending to be legally bound, I have hereunto set my hand this date as entered below:      

NAME :
DATE:                                    


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