Future Alumni Information Submission Form

Please provide the following contact information to be entered into the Henderson State University Alumni Database.
Use the Tab Key to move from item to item.

Name:
Last First

Middle Maiden Name

Preferred Name (If different)

Social Security Number

Permanent Address: (an address you can receive mail from us)
Street
City State Zip Code
County:
Telephone Number (with area code)

E Mail Address (other than Henderson's)

Birth Date (Month/Day/Year): //

Gender:

Male
Female

From which high school did you graduate?
City State What year did you graduate?

When do you graduate? Month. /Yr.

Major Degree I attended from to

Activities while attending Henderson (please select all that apply by pressing Ctrl while selecting with mouse):
Sports Baseball Basketball Cross Country Football Golf Softball Swimming Tennis Track Volleyball Other (specify):	Greeks Alpha Kappa Alpha Alpha Phi Alpha Alpha Sigma Tau Delta Sigma Theta Delta Zeta Kappa Alpha Psi Phi Beta Sigma Phi Lambda Chi Phi Sigma Kappa Sigma Phi Epsilon Sigma Tau Gamma Other (specify):	Other Band-Marching, Concert, Jazz Cheerleader Choir-Concert, Chorale Debate Drama Heart and Key ROTC Student Government Other (specify):

Did you receive any scholarships? If so, which one:

Spouse's Name: Maiden Name:
Is spouse a Henderson graduate or attended HSU? Yes No

If yes:
My spouse graduated from Henderson in Major Degree
If not a graduate, years attended: Social Security Number
From which high school did he/she graduate?
School: City: State:

Spouse's activities while attending Henderson (please select all that apply by pressing Ctrl while selecting with mouse):

Sports

Other (specify):

Greeks

Other (specify):

Other

Other (specify):

Children (Names and Birth Dates):

I am interested in serving on the Alumni Board:

as a class agent

in placement

Other:

I am not interested in serving on the Alumni Board.

Do you want information about you released in the REDDIE REPORT? (i.e. promotions, engagements, weddings, births, deaths)? Yes No

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