Student Success Stories to Celebrate!

	Wanted! Student Success Stories to Celebrate!

	The purpose of this form is to gather initial information about current or former students whose experiences could be celebrated. Story information may be publicized in upcoming ESBOCES/Academy media. Someone from Public Relations will follow up shortly.

	Part I - Information About the Student

	Name:*

	Student Status:*
	Student Status:* Current Student Former Student

	Best phone number(s) to reach student:

	Student Email:

	Program:

	Year(s) of Attendance:

	What do you want to share?*

	Part II - Information About You

	Relation to student above:*
	Relation to student above:* Self Staff Member Parent Other, please specify

	May someone from ESBOCES contact you?*
	May someone from ESBOCES contact you?* YesNo

	Name:

	Phone number:

	Email: