Future Faculty Fellowship Release Authorization

Future Faculty Fellowship (FFF) recipents that possess a minimum of a Master's degree may request to have their professional information posted online.

I understand and agree that my authorization will be signed electronically when I select the check box below. I also understand that my electronic signature means that I agree to posting information I provided on a public web site.

Checking the box below also indicates that I grant permission for a KCP representative to contact me via e-mail with follow up surveys and that I will respond to those surveys in a reasonable amount of time.

* Today's Date: mm/dd/yyyy

* Last Name:
* First Name:
* Middle Initial:
* Birthdate: mm/dd (for verification only, will not be published)
* Email:
* Phone: xxx-xxx-xxxx (for verification only, will not be published)

University that awarded Fellowship

Provide degree and field of study: Masters - Field Study:
Masters - Field Study:
Masters - Field Study:
Doctorate - Field Study:

Authorization box below must be checked prior to submission or request is not valid. * I Authorize

**Please print completed form and keep for your records before submitting.

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Future Faculty Fellowship Release Authorization