ETCS Scholarships for Excellence

Media Waiver Form

By signing below, I give my consent to the College of Engineering, Technology, and Computer at Indiana University-Purdue University Fort Wayne to use my name, comments, photograph or to be videotaped in order to promote ETCS Scholarships for Excellence Program.

Text Box: _______________________________________________________________________ SignatureDate Name (Printed)____________________________________________________________ Address:________________________City:____________State:______ Zip: __________ Phone: Home______________ Work_______________ Age: _____ Sex: _____

Text Box: For those persons under the age of eighteen (18) years: I hereby consent and agree to the above as the Parent/Legal Guardian of _____________________________(minor’s name). ______________________________________ ____________________________ Parent or Legal Guardian Print Name

 

 

 

 

 

 

Please return completed form along with your scholarship application to:

Gerard Voland, Dean
College of Engineering, Technology, and Computer Science
2101 E. Coliseum Blvd.
Fort Wayne, IN 46805-1499