2011 Jireh Prep Student Application by TBd92btU

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									                         STUDENT ATHLETE APPLICATION




                          JIREH PREP ATHLETICS INC.

STUDENT INFORMATION
Student Athlete name___________________________________________________

Street Address ________________________________________________________

City, State, Zip _______________________________________________________

Date of Birth _____________________

Cell phone # ______________________ Home phone#_______________________

Email Address ________________________________________________________

Football coach’s name__________________________________________________

Coach’s phone # ___________________

Have you ever been dismissed academically? YES or NO

Have you ever been dismissed for disciplinary reasons? YES or NO

Have you used alcohol, tobacco, or any illegal drugs during the past 6 months? YES or NO

How did you hear about us? __________________________

Name of church you attend? _________________________

Pastor’s name ______________________       Telephone ______________________

Have you ever been convicted of a ‘FELONY’? If yes, explain by attaching a one page paper

What was your latest 40-yd dash time? __________

What position do you play? _____________

Height: ___________________     Weight: ________________________

Bench Press _________________________ Squat ________________




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                          STUDENT ATHLETE APPLICATION


ACADEMICS
Last High School Attended ________________________


Guidance Counselors name and telephone number: ____________________________


Have you taken either of the two or both?


SAT    Y or N If yes, score _____________ (Two Part/Verbal and Math scores ONLY)

ACT    Y or N   If yes, score _____________ (Total combined score NOT your composite score)


GPA ______      Core GPA (if known) ___________


Are you currently receiving IEP services at your high school? Yes or No


Are you currently passing your high school courses now? If not, why? What are you failing?

_____________________________________________________________________

_____________________________________________________________________

Are you graduating with your freshman class? Have you failed any grades? If so, explain:

_____________________________________________________________________

Will you be lacking any core courses after graduation? If yes, what?

_____________________________________________________________________

Have you taken 2 years or are you taking your 2 nd year of a foreign language (2 yrs of the same language)?

_____________________________________________________________________

Have you been contacted by any colleges? If so please provide names of colleges and coaches.

_____________________________________________________________________

What are your career goals?

_____________________________________________________________________


_____________________________________________________________________




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                        STUDENT ATHLETE APPLICATION


PARENTS
Mother’s Name & Occupation _________________________________________________________

Mother’s address (if different from student) _______________________________________________

_________________________________________________________________________________

Mother Home Phone#____________________________

Mother Cell Phone# _____________________________

Email Address______________________________________________________________________


Fathers Name & Occupation___________________________________________________________

Father’s address (if different from student) ________________________________________________

__________________________________________________________________________________

Father Home Phone #_________________________________

Father Cell Phone # __________________________________

Email Address______________________________________________________________________



Emergency contact _____________________________________

Home phone # ______________________

Cell phone # _______________________

Alternate #_________________________



Student/Athlete Sign __________________________________________________________


Parent/guardian Sign __________________________________________________________


Date ______________


*ALL COMPLETED APPLICATIONS MUST BE ACCOMPANIED
WITH A $25 PROCESSING FEE, TRANSCRIPTS, AND TEST SCORES
(SAT/ACT).

MAKE MONEY ORDERS PAYABLE TO JIREH PREP. NO
PERSONAL CHECKS WILL BE ACCEPTED.
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                        STUDENT ATHLETE APPLICATION


         Criminal Background Check and Drug Test Authorization



I, ___________________________________ understand that before I can complete my
enrollment at Jireh Prep, I MUST submit a criminal background check prior to my
arrival. I also understand it is required to submit a drug screening via a urinalysis to
complete my enrollment. Refusal or a negative report of the criminal background check
could result in a denied admittance. Refusal of the drug screening will result in a denied
admittance. A positive drug screening while enrolled at Jireh Prep will lead to an
automatic expulsion and forfeiture of all tuition paid. Jireh Prep has sole discretion of all
consequences.



I, ____________________________________ give permission to the Jireh Prep
Athletics staff or a outsourced drug screening company to administer a drug screening at
anytime during my enrollment with Jireh Prep.


Please Print:


Full Name __________________________________________________________


Street Address __________________________________________________________________________


City, State, Zip _________________________________________________________________________


Phone Number ___________________________________________________


Social Security # ________ - ________ - _____________


Signature: _____________________________________________________________


Parents Signature (only if under 18) _________________________________________________


Date: _________________________________________




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