GED/HSED Application

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* 1. First Name:

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* 2. Middle Name:

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* 3. Last Name:

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* 4. Date of Birth:

Date

Date

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* 5. Address:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 6. Audio and Visual Release Statement

(Please review and check yes or no)

I give permission to Lac Courte Oreilles Ojibwe University (LCOOU) to use my name, portrait, picture, video or audio equivalent for the purposes of use on the internet, publication, viewing, display, sound or training purposes.

I agree all such material shall remain property of LCOOU.

I also understand that the material will be used in good taste and without discrimination.

Yes

No