Last Name:
First:
Middle:
Preferred Name:
Street:
City:
State:
Zip:
County:
Email:
Home Phone:
Date of Birth:
Age:
Church Preference:
Last 4 digits of SSN:
Father's Name:
Occupation:
Business Phone:
Mother's Name:
High School:
Counselor:
Address:
Phone:
Date of Graduation:
Cumulative GPA:
Rank in Class: of
Test Scores: ACT Composite:
SAT Math: Verbal:
J.C. Transfer Yes No
Name of School:
GPA
Hours Passed
Course of Study you wish to pursue at UC:
Date of Expected College Entrance:
Supervising Athletic Trainer/Coach:
Office Phone:
Years as Student Trainer:
Sports Worked With:
Sports Participate In:
CPR Certified: Yes No
First Aid Certified: Yes No
Seeking KY Athletic Trainer Certification: Yes No