City of Gainesville: Student Engagement

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Name *

Email *

Race *

White

Hispanic or Latino

Black or African American

Native American or American Indian

Asian / Pacific Islander

Other:

Required

Level of Education *

Undergraduate Student

Graduate Student

Other:

Year *

1st

2nd

3rd

4th

5th

Other:

Major *

Where is your hometown? *

How long have you been living in Gainesville? *

What neighborhood do you live in? (you could put your apartment complex if you don't have a particular neighborhood) *

Favorite thing about Gainesville

I hereby give my consent to the City of Gainesville, its affiliates and agents, to use my image and likeness and/or any interview statements from me. This consent includes: (a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice; (b) Permission to use my name; (c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole. *

I consent

I do not consent

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