Dutchmen Cross Country Questionnaire

GENERAL INFORMATION:
First Name:
Middle Initial:
Last Name:
Telephone:
Address:
City:
State:	Zip:
Mother/Guardian:
Occupation:
Business Phone:
Father/Guardian:
Occupation:
Business Phone:
Brothers:
Sisters:
Email Address:
Cell Phone:
Date of birth:
Gender: Male Female
ACADEMIC INFORMATION:
Name of High School:
Guidance Counselor:
S.A.T. Scores: CR: M: W:
ACT Score:
Class Rank: out of
Please list your academic interest(s) or major field(s) of study:
Date you will graduate from high school: Month: Year:
ATHLETIC INFORMATION:
	Height: Weight:
5,000m Cross Country - 3.1 mile: Time:
1,600m - mile: Time:
Road Race Distance: Time:
3,200m - 2 mile: Time:
800m - half mile: Time:
400m - quarter mile: Time:
Coach's Name:
Home Phone:
Office Phone:
What other varsity sports do you want to play in college?
Friends/relatives attending or graduates of Lebanon Valley: