Questionnaire

Personal Information

* Denotes required fields
First Name: *
Last Name: * MI:

Mailing Address:
Street: *
City: * St: * Zip: *
Telephone:
Email: Age:
Date of Birth: Gender:
Height: Weight:

Scholastic Information

High School:
City:
Grad Date: *
Class Rank:
ACT/SAT Score:
HS GPA: College Transfer GPA:

Cross Country Information

Please indicate if personal record is from a Road Race (RR).
Best 5K: Best 3 Mile:

HS Coach:
Phone:
Club Coach:
Phone:
College Coach:
Phone:

Track & Field Information

Event: Best Mark:
Event: Best Mark:
Event: Best Mark:
Event: Best Mark:

HS Coach:
Phone:
Club Coach:
Phone:
College Coach:
Phone:

Additional Information

Strengths: (speed, strength, endurance, mentally tough)

Honors:
Records:

Today's Date: *

Derek Kite
Head Track & Cross Country Coach
York College
1125 East 8th Street
York, NE 68467
Fax: (402) 363-5738
Email: dkite@york.edu

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