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Athlete Questionnaire
|US Citizen |Foreign Citizen|

Us Citizen Questionnaire
First Name
Last Name
Middle Name
Address
City
State	Zip Code:
Home Phone
Work Phone
Cell Phone
Fax Number
Email
SSN
License Number
	How did you hear about our office?

Biographical Information
Date of Birth
Height
Weight
Sport
Position
Place of Birth
Sex	Male Female
Children	Yes No
Marital Status	Single Married Divorced Widowed
Parent/Legal Guardian
Address
City
State	Zip Code
Alternate Contact
Address
City
State	Zip Code

Athletic Information
	High School Sports History
Name
City
State	Years
	College Sports History
Name
City
State	Years
	Professional Sports History
Name
City
State	Years
	Names and phone numbers of your coaches

	List any awards that you have received:

	Are there any disciplinary or eligibility issues involving your status as an athlete?

	Have you ever been arrested, charged or convicted? If yes, when and what for?

	Do you have a current training routine? If yes, how often and describe

	Have you ever been injured, had any operations, or taken time off? If yes, please explain:

	Please describe any long-term goals that you have.

	Items in bold are required