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 Basketball Potential Player Questionnaire

Illinois Valley Community College                          
Attention: Men's Basketball
815 N. Orlando Smith Avenue
Oglesby, IL 61348                                      Please print or write legibly.

Or e-mail to Tommy_Canale@ivcc.edu                                      

Name: ___________________________  ________________________  _______________
                (Last)                                             (First)                                        (Middle)

Personal Information

Home Address ______________________________________________________________

City _____________________________ State _______ Zip ___________

Date of Birth _________________ Social Security Number ______-_______-______

E-mail Address __________________________Cell Phone _______________________

Home Phone ____________________________

High School _____________________________________Year of Graduation _________

Coach's Name _________________School Phone _______________ Home Phone _______________

Parent's or Guardian _________________________________ Occupations _____________________

Other Children in your family and age(s) __________________________________________________

Friend's or Alumni at IVCC that you know? _______________________________________________

Other Schools that you are considering? __________________________________________________

Athletic Information

Position______ Height_____ Weight_____ Pts./Game____ Reb./Game_____Asst./Game____ Ft%____

FG%____ 3Pt.%____ Position you would like to play in college? _______ Jersey #_______

Shoe Size _______ Which is your dominant hand, Left or Right?_____

Name of the most influential person in your life__________________________________

List of Honors and Awards_____________________________________________________________

Name of the best player you played against?____________________ His High School________________

List of your strengths as a player_____________________________ Weakness____________________

List your future goals_____________________________________________

Academic Information

Rank in Class__________ GPA__________ ACT Score__________ SAT Score_______________

Are you registered with the NCAA Clearinghouse?_________ Are you a NCAA Qualifier?____________

What would you like to major in?________________ Other college(s) attend_______________________

Counselor's Name_____________________________ Office Phone____________________________

Principal's Name_______________________________

 Date Completed ___________________

*Please note:  Effective Fall 2013 all student athletes will be required to have primary
health insurance.  If you do not have primary insurance, please contact the Head Coach
and he will give you additional information regarding this matter.