2026 Scholarship Application Media Release Form-College

MEDIA RELEASE FOR COLLEGE SCHOLARSHIP APPLICANT

Applicants must submit a signed Media Release Form to be eligible for Scholarship Awards.
CONSENT TO PHOTOGRAPH, FILM, OR VIDEOTAPE A STUDENT FOR NON-PROFIT USE (e.g. educational or public service purposes)
Applicant's Name*

First NameLast Name
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*

Area CodePhone Number
College Name*
Media Release Form
THE MEDIA RELEASE FORM MUST BE SUBMITTED NO LATER THAN MARCH 1, 2026 AT 11:59 P.M. CST.
- I hereby consent to participate in an interview and the use of quotes, photography, movie, video of the above name student to be used by Delta Sigma Theta Sorority, Inc. Birmingham Alumnae Chapter.
- I grant permission to Delta Sigma Theta Sorority, Inc. Birmingham Alumnae Chapter the rights to edit, use, reproduce the interview or photographs for marketing, not limited to print, internet and all other forms of media.
- I hereby release Delta Sigma Theta Sorority, Inc. Birmingham Alumnae Chapter and its members from all claims, liabilities and demands in connection with this scholarship application process.
- I grant permission to Delta Sigma Theta Sorority, Inc. Birmingham Alumnae Chapter and its members to obtain a copy of my transcript, if necessary.
Your signature hereby constitutes an electronic signature for this document.
Signature of Applicant: *

Clear
Date

MonthDayYear
Date
Should be Empty:

Media Release Form