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Box 1418 Andalusia, AL 36420 (334) 222-6591, ext. 2002 Prospective Student - Athlete Basketball Questionnaire _______________________________________________ _________________________ Full Name Preferred Name (______)_______________ _______-_____-_______ _________________________ Phone Number Social Security Number Date of Birth (M/D/YR) _____________________________________________________________________________ Mailing Address City State Zip Code _____________________________________________________________________________ Primary Position Secondary Position Height Weight _____________________________________________________________________________ Scoring Average Rebound Average Assists Average ___________________________________________________ (____)_________________ Fathers Name Occupation Business Phone ___________________________________________________ (____)_________________ Mothers Name Occupation Business Phone Living with: (circle one) Mother Father Both Other ____________________ Certified by Clearinghouse: Yes_____ No_____ Index Number ____________________ ___________________________________________ _______________________________ Current School Basketball Coach ___________________________________________________ ______________________ School Address City State Zip Code Coachs Number __________________________________ ______________ _______________ High School Grade Point Average ACT Test Score SAT Test Score __________________________________ ____________________________________ Potential College Major 1 Potential College Major 2     Lurleen B. 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