2023 Graduation Recognition Form

Graduation Recognition Program Survey Form

Graduation Recognition Form Deadline: June 5, 2023
This form provides information for the graduates who would like to participate in the 2023 Kettering Baptist Church (KBC) Graduation Recognition Program. The information below will assist the Scholarship Ministry in planning the program. All graduates must complete this form. This is not the Scholarship Application. The Scholarship Application is on a separate form on the KBC website. If the student is under 18 years of age, this form must be completed by a parent or guardian.
Is Student under 18 years of age?*

YesNo
Name*

First NameLast Name
Gender*

FemaleMale
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Telephone Number*
Parent's Cellphone Number*
Graduate's Cellphone Number*
Email address*

Confirmation Emailexample@example.com
Date student became a member of Kettering Baptist Church. (Students graduating from High School and below, may use their parents/guardian membership date.)*

MonthDayYear
Date parent became a member of Kettering Baptist Church

MonthDayYear
Name of School Graduating From*
School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Level of Education*

Pre-SchoolKindergardenElementary SchoolMiddle SchoolHigh SchoolBachelor's DegreeMaster's DegreePhD
Would you like your picture included in the Program? Pictures must be emailed to scholarship@ketteringministries.org. Subject: Graduation Picture*

YesNo
I, (age 18+ and/or parent/guardian) give Kettering Baptist Church, Inc., hereinafter Kettering Baptist, permission to use my and/or my child’s, likeness, image, voice, information and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images and the like. I agree that Kettering Baptist has complete ownership of such pictures, etc., including the entire copyright and may use them for any purpose consistent with the mission and ministry of Kettering Baptist. These uses may include, but are not limited to: livestream broadcasts, illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements and any promotional or educational materials in any medium now known or later developed, including the Internet. I acknowledge that I will not receive any compensation, etc. for the use of such pictures, etc., and hereby release Kettering Baptist and its agents and assigns from any and all claims which arise out of or are in any way connected with such use. I have read and understand this consent and release.*

AgreeDecline
THE INFORMATION REQUESTED BELOW IS FOR STUDENTS GRADUATING FROM HIGH SCHOOL AND ABOVE
Description of scholastic achievements: ex. leadership, ministries, awards, honors, memberships, sports, volunteer/community service or other extracurricular activities.*
..Your answer
Describe your plans for next year: College, University, Military Service, Technical School or future employment.*
Your answer
College, University, Military, technical school you will attend in the fall/winter 2023, or your future place of employment.*
Your answer
Prospective Major*
Should be Empty:

Graduation Recognition Program Survey Form