Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Award Category (Please check all that apply)

Development

Competition

Use of Name

May we use the APPLICANTS name in social media and press announcements?

Complete Name

First Name ONLY

Please DO NOT use applicants name in any public/social media

Use of School Name

May we reference the school the Applicant attends and their grade? Often schools and community papers will publish the press release.

Please DO NOT reference school or grade

Yes you may reference

Photo Permission

May we use a photo of the Applicant? Will the Applicant be available for Interviews?

Applicant or Parent/Guardian of Applicant grants Irish Traditions Atlanta (ITA) to use photos of the Applicant on the ITA Website, Facebook, and in press releases regarding the Irish Traditions Atlanta Scholarship.

The Applicant is available for interviews if the opportunity arises.

Date of Signature

MM

DD

YYYY