Summer College Alumni
Ambassador Permission Form
(Note: This form is for both Summer College alumni and their parents/guardians.)
Many prospective Summer College students and parents want to talk with someone who has participated in a Summer College program.
If you are willing to be contacted occasionally by potential applicants and/or their parents, please:
- Let us know how you would like to be contacted by providing us with your phone number, e-mail address, or both.
- Print this form.
- If you are a Summer College student, have your parent or guardian sign the permission section of this form. We must have their signature before releasing your contact information to Summer College applicants.
- Mail the completed and signed form to: Cornell University Summer College Ambassador Program; B20 Day Hall; Ithaca NY 14853.
We will share your contact information only when an applicant asks to talk with a Summer College alum and/or parent/guardian. If at any time you wish to be removed from this list, simply contact us and we will remove your name.
Thank you. We appreciate your willingness to talk about your Summer College experience with others!
Student Name and Address
| First name: | |
| Last name: | |
| Phone: | |
| E-mail: | |
| Address: | |
| City: | |
| State or province: | |
| Postal code: | |
| Country: |
Only provide your complete mailing address if it has changed since you attended Summer College. We will not give this information out to anyone.
Parent/Guardian Name and Address
| First name: | |
| Last name: | |
| Phone: | |
| E-mail: | |
| Address: | |
| City: | |
| State or province: | |
| Postal code: | |
| Country: |
Which program did you attend?
| Program | Year attended |
| [ ] One-week Program | |
| [ ] Three-week Program | |
| [ ] Four-week Program | |
| [ ] Six-week Program |
Your school:
| High School name: |
Parent/Guardian permission:
I hereby grant my permission to Cornell University Summer College to release the above contact information for me and/or my son/daughter to individuals who have requested more specific information about Summer College. I release and hold harmless Cornell University from claims of any nature arising while I am and/or he/she is participating in such activities.
| Name (please print): | |
| Signature: | |
| Relationship: |