Student-Athlete Application
1350 Old Skokie Rd. Suite 205| Highland Park, IL 60035 |
847-748-8190 |
Please read this form carefully and complete form in its entirety.Application due date January 9, 2015
Applicant’s Current Information Date of application: ______
Name: ______Gender:______
Address: Apt#:______
City/State/Zip Code: ______
Student Cell Phone Number: ______Student Email Address: ______
Birth Date: ___/___/____ Ethnicity (Optional): ______Age: ______
Parent/Guardian Information
Parent/Guardian Name(s):______
Parent/Guardian Email Address:______
Parent/Guardian Home Phone: (____) ______
Parent/Guardian Cell Phone: (____) ______
Employer: ______
Employer’s Phone Number: (____) ______
Emergency Contact Information
Emergency Contact Name:______
Relationship of Emergency Contact to Student: ______
Emergency Contact Phone: ______
Household Information
Please list names of all people in household, age, and relationship to student:
1.______
2.______
3.______
4.______
Educational Information
School Name: ______Current Year: ______
Current Cumulative GPA: ______Expected Graduation Year: ______
Favorite subject(s) in school: ______
Subject(s) you would like help with: ______
Completed ACT: Yes No Completed SAT: Yes No
If yes, please list dates taken and score(s) received: ______
Guidance Counselor’s Name: ______
Guidance Counselor’s Email Address:______
Guidance Counselor’s Phone Number: ______
Referral Source to Beyond Sports Foundation: ______
Athletics (Student)
All Sports played in high school:
Current sport of interest:
Positions played in sport of interest:
Years of experience in sport of interest:
Highest Level (JV, Varsity, etc.):
Current Coach’s Name: Sport Coached:
Coach’s Phone Number:
Future Athletic Goals:
Is applicant currently training? Yes No
Has applicant ever received extensive training outside of school? Yes No
Extra-Curricular Activities
Please List all Extra Curricular Activities:
Work Experience
Have you ever had a job? Yes No
If yes: Where did/do you work:
What was/is your job title?
What were/are your responsibilities?
Are you currently working? Yes No If yes, where: ______
Health Information
Please list any:______
Health Problems or Allergies: ______
Learning disabilities or special needs (IEP):______
Medical History
Have you experienced any of the following?
Yes NoHeart attack, coronary bypass or other coronary surgery?
Yes NoChest discomfort (especially with exertion)?
Yes NoHigh blood pressure?
Yes NoExtra, skipped, or rapid heartbeats / palpitations?
Yes NoHeart murmurs, clicks, or unusual cardiac findings?
Yes NoRheumatic fever?
Yes NoAnkle swelling?
Yes NoPeripheral vascular disease?
Yes NoPhlebitis, emboli?
Yes NoUnusual shortness of breath?
Yes NoLight headedness or fainting
Yes NoPulmonary disease (e.g. asthma, emphysema or bronchitis)?
Yes NoAbnormal blood lipids (cholesterol, triglycerides)?
Yes NoStroke?
Yes No Recent illness, hospitalization or surgical procedure within the past six months?
Yes NoMedications of any kind? (If yes, list) ______
Yes NoDiabetes or other metabolic disorders?
Yes NoAre you pregnant now?
Yes NoIs there any reason your physician would object to your dieting?
Yes NoIs there a history of heart disease in your family?
Yes NoIs there any reason your physician would object to your exercise?
Yes NoDo you smoke or chew tobacco (cigarettes / dips per day) ______
Yes NoIngest alcohol? (wines, beers, or drinks per day) ______
Old and recent injuries (if any): ______
Food/Drug Allergies:
______
Other health conditions or medical problems not mentioned above: ______
Physician’s Full Name: ______
Physician’s Phone #: ______
Physician’s Address:
City______State______Zip______
Student Name: ______School: ______
The Beyond Sports Foundation is a 501 (c) (3) non-profit organization dedicated to providing educational, athletic, and social support for disadvantaged, athletically talented high school students within the Chicago metropolitan area. BSF’s goal is to place each student-athlete in an affordable and appropriate college environment with a full or partial NCAA scholarship.
To reach this goal, Beyond Sports Foundation may need access to some of the student-athlete’s information, including academic transcripts, ACT information, NCAA eligibility information, and verification of economic standing (i.e. participation in the free lunch program, which confirms eligibility for some fee waivers). Beyond Sports Foundation uses this information strictly for the purposes of ensuring that student-athletes are on track for ACT testing, NCAA eligibility, and for addressing academic support when needed.
●I hereby consent to allow the Beyond Sports Foundation access to all academic records (transcripts, ACT, PSAT, SAT, and other test scores) and athletic records (including status of NCAA eligibility) of the student-athlete named above. This includes any online services that display this information.
●I also hereby release the Beyond Sports Foundation and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above.
If your school uses any type of online grade book please provide the website, user name, and password. This will enable BSF to regularly check the student athlete’s progress.
Website:
User Name: Password:
Signature of Student: Date:
Signature of Parent/Guardian: Date:
Print Name of Counselor:
Essay Questions
Applicant name: Date:
Please answer the following question to the best of your ability. Your response should be at least 250 words in length.
Why do you want to be a part of the Beyond Sports Foundation? How will you both benefit and contribute to the Beyond Sports Foundation? Please use a separate sheet of paper to answer the questions.
When returning this application please include the following forms:
●Completed Student Application and Beyond Sports Financial Form.
●School Transcripts (Unofficial or Official).
●A picture of yourself.
●Two Letters of Recommendation from your Athletic Coach and a core Teacher (Math, Science, English).
●Please do not submit an incomplete or late application.Candidates with incomplete or late applications will not be considered for acceptance.