Elizabeth City State University
Student-Athlete Questionnaire
PLEASE PRINT CLEARLY IN BLACK INK!!!! SPORT__________________________ DATE__________
FULL NAME___________________________________________________ PREFERRED FIRST NAME ____________
EMAIL ADDRESS_________________________________________________ CELL PHONE #: __________________
HEIGHT: _____ WEIGHT: ____ BIRTHDATE __/__/__ BIRTH PLACE______________________________________
(month/date/year) (City, State, Country)
HOME ADDRESS: _______________________________________________________________________________
(Street Number, Town, State, ZIP CODE)
PARENT(s)/GUARDIAN: __________________________________________ PHONE #: ______________________
PARENT/GUARDIAN: ____________________________________________ PHONE #: ______________________
PARENT/GUARDIAN: ____________________________________________ PHONE #: ______________________
SIBLINGS (Names and current ages): _______________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
RELATIVES WHO HAVE PARTICIPATED IN INTERCOLLEGIATE ATHLETICS (Name, relationship, School, Sport, Years):
_____________________________________________________________________________________________
HIGH SCHOOL(S): _______________________________________ CITY/STATE: _____________________________
GRADUATION YEAR: ___________ ACADEMIC HONORS/AWARDS: _______________________________________
_____________________________________________________________________________________________
SCHOOL’S ATHLETIC CONFERENCE(S): ______________________________________________________________
HIGH SCHOOL VARSITY SPORTS (Season on VARSITY team ONLY!!!)
SPORT SEASONS POS./EVENTS HEAD COACH HONORS/AWARDS/RECORDS/CHAMP.
_____________ _____________ _____________ ______________ ____________________________________
_____________ _____________ _____________ ______________ ____________________________________
_____________ _____________ _____________ ______________ ____________________________________
_____________ _____________ _____________ ______________ ____________________________________
OTHER COLLEGES, UNIVERSITIES AND PREP SCHOOLS ATTENDED:
INSTITUTION: __________________________________ CITY STATE: ____________________YEAR(S): __________
Did you participate in intercollegiate sports? YES NO (Please circle one)
If YES: SPORT: ____________________ SEASONS: _____________ HONORS, AWARDS: ______________________
INSTITUTION: __________________________________ CITY STATE: ____________________YEAR(S): __________
Did you participate in intercollegiate sports? YES NO (Please circle one)
If YES: SPORT: ____________________ SEASONS: _____________ HONORS, AWARDS: ______________________
At ECSU
Clubs, societies, groups that you are a member of at ECSU: _______________________________________________
_____________________________________________________________________________________________
Academic Honors, scholarships, etc.: _______________________________________________________________
_____________________________________________________________________________________________
List the top three reasons that you chose ECSU: ______________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
By signing this form, you agree that the Elizabeth City State University Sports Information Department may release and publish any pertinent information from this form for the sole purpose of promoting the athletic department and the specific program at Elizabeth City State University. This information will NOT be given to the public or used in any other manner.
___________________________________________ DATE:___________________
Signature
