Basketball Questionnaire - Mississippi Prep Hurricanes

The Mississippi Prep Student Athlete Application

Availability
Choose all that apply

Choose a time during the day you are available for a call with us.

Athlete Information
First Name

Last Name

Height

Weight

Position(s)

Dominant Hand

Contact Number

Full Address (city, state, zip)

Last School Attended

Highest Grade Completed

Did you graduate?

GPA

ACT

DOB

Any offers previously?

If yes, name of school?

Colleges you're interested in attending?

NCAA ID Number?
I provided my NCAA ID Number. I currently do not know or do not have an NCAA number. I understand my NCAA number must be provided for all NCAA student reporting purposes prior to the completion of the program.

Twitter Handle

Instagram Handle

Hudl/Film Handle

How did you find The Mississippi Prep?

Athlete Medical Information
Name of Health Insurance

Policy Number

Hospital Preference
I understand individual Health Insurance is mandatory. Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures)The purpose of this information is to ensure that medical personnel has details of any medical problem which may interfere or alter treatment.

Is the above student presently being treated for an injury or sickness, or taking any form of medication for any reason?

If yes, please explain

Is the above student allergic to any type of food or medication?
If yes, please list information

Parent/Guardian Information
Household Type

Parent Household Income (per year total)
Select one of the following:

Mother First Name

Mother Last Name

Mother's Email

Mother's Address

Mother's Place of Employment

Father First Name

Father Last Name

Father's Email

Father's Address

Father's Place of Employment Phone Number

Father's Place of Employment