SOP - ASPIR2E PPAP Media Consent Release Form - Spring 2023

Periodically, the Texas A&M Rangel School of Pharmacy publishes and submits stories to the news media that highlight student achievement, accomplishments and other noteworthy endeavors. With your permission, the information requested below may be used in a news article or included in School of Pharmacy publications and marketing efforts (e.g., event programs, School newsletters, Annual Reports, etc.).

Name Name * First Middle Last
Hometown (typically defined as where you were born or where you grew up) *
Birthplace (if different than hometown) *
Name of High School You Graduated From *
City *
State *
Parents’ Names (Mother) *
Parents’ Names (Father) *
Parents’ Residential Address Parents’ Residential Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
College(s) or University(ies) you attended or from which you received degrees:
School Name, Major, Degree Received, Date *
2. I give the Texas A&M Rangel School of Pharmacy permission to release or use my information and likeness (e.g. academic achievements, student organization involvement, scholastic activities, photos and videos, etc.): Check all that apply. *

2. I give the Texas A&M Rangel School of Pharmacy permission to release or use my information and likeness (e.g. academic achievements, student organization involvement, scholastic activities, photos and videos, etc.): Check all that apply. To the news media In School of Pharmacy, Texas A&M, and Texas A&M Health Science Center publications On the School website On the School’s social media platforms I DO NOT want my information or likeness released to the news media or used in any publication.
Draw your signature into the box below. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date * / MM / DD YYYY