RELEASE FORM FOR BROOMSEDGE  CHRONICLES

As a part of an English class on the WKU-Glasgow campus, the student bearing this form has been assigned to interview an individual in the south central Kentucky area.  The purpose of the interview is to preserve the history of the area in a compilation of student writings called Broomsedge Chronicles .  Your cooperation is appreciated.

Title of Essay:____________________________________________________

Name of Student Interviewer: ________________________________________

Signature of Student Interviewer: _____________________________________

Name of Individual Interviewed: ______________________________________

Signature of Individual Interviewed: ____________________________________

Date: ______________