Name Gender
Class Year Major
Campus Address    
Email Address Job Title/Position
Parent's Address Zip Code
Hometown Newspaper(s) if known

Parents' names, as they should be listed in the news release
(please note if parents have a different hometown address than above)

  

High School Name Graduation Year
College/University Name Graduation Year

Activities/involvement at IUP (e.g., residence assistant, athletics, Provost's Scholar.
Box Describe the Who? What? Where? Why? How? Provide 10 lines


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