Issuu on Google+

PLEASE PRINT CLEARLY

PLEASE PRINT CLEARLY

Name: __________________________ Age: ______

Name: ___________________________ Age: _____

I am a (M / F) interested in (M / F)

I am a (M / F) interested in (M / F)

Daytime Phone Number: _________________________

Daytime Phone Number: __________________________

Contact Email: ____________________________________

Contact Email: ____________________________________

Information Release

Information Release

By signing this release form, you agree to have your name and email disclosed to participants of this event. You are also agreeing that you are of 18 years of age or older. USU Program Council is not responsible for contact between participants outside our informational email.

By signing this release form, you agree to have your name and email disclosed to participants of this event. You are also agreeing that you are of 18 years of age or older. USU Program Council is not responsible for contact between participants outside our informational email.

*Phone numbers will not be disclosed to participants. It is for USU Program Council use only.

*Phone numbers will not be disclosed to participants. It is for USU Program Council use only.

By checking this box, you are giving permission to have your photo taken during the event for marketing purposes.

By checking this box, you are giving permission to have your photo taken during the event for marketing purposes.

Signature: __________________________________

Signature: __________________________________

Date: __________________

Date: __________________


Speed Dating Application FALL 2011