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Basketball Potential Player Questionnaire

Illinois Valley Community College
Attention: Women'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 _____________ E-mail Address ______________________________

Cell Phone ____________________Home Phone __________________________

Social Security Number ______-_______-_______ Year of Graduation __________

High School __________________________School Phone ___________________

Coach's Name ________________________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?____________________________________

Her 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.