Prospective Player Questionnaire Form

Note: Coffeyville Community College does not accept walk-on players. After filling out this form, please send game videos to Coach Jared Powers at the following address:

Coffeyville Community College
ATTN: Jared Powers
400 W. 11th St.
Coffeyville, KS 67337

General Information

Name (First, Middle, Last): Date of Birth (MM/DD/YY): //

Place of Birth:

Home Address: City:

State: Zip Code:

Home Phone Number (include area code):

Cell Phone Number (include area code):

Best Time to Call (Day or Night):

Email Address:

Mother's Name: Mother's Occupation:

Mother's Phone Number (include area code):

Father's Name: Father's Occupation:

Father's Phone Number (include area code):

Whom do you live with?

Person you will consult with when making a decision about college:

Athletic Information

High School: High School Coach:

City and State: Coach's Office Phone (include area code):

Position: Jersey #: Height: Weight: 40-Speed:

Bench Press: Squat: Power Clean: Vertical Jump:

Other Sports Played:

Athletic Honors:

Previous Injuries:

Surgeries & Dates:

College Preferred Position:

Academic Information

Counselor's Name: Counselor's Phone (include area code)

H.S. GPA: H.S. Core Units: Core GPA: H.S. Rank:

ACT Score: ACT CUM Score: SAT Verbal Score: SAT Math Score:

ACT Test Date(s): SAT Test Date(s):

NCAA Clearinghouse Registration Date:

Academic Honors:

Planned College Major:

What is your interest in Coffeyville: Very High High Minimum Low