EmailMe Form - Mullen's Great Midwest Shootout APPLICATION

Full Name *

First Last

Home/Parent Phone *

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Cell Phone *

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Home Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Height *

Weight *

GPA *

ACT/SAT Score *

College Credit Hours Earned *

Current Grade *

Junior College Sophomore

Junior College Freshman

Post-Grad

High School Senior

Email *

Twitter

Position *

Current School *

Current School's City *

Current School's State *

Coach's Name *

First Last

Coach's School Phone *

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Coach's Cell Phone *

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Coach's Email *

Additional information that could assist in your recruitment including awards & accomplishments

How many years of playing eligibility do you have remaining? *

Health Insurance Company *

Insured's Name *

Policy # *

Group # *

Insurance Company Phone *

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RECOMMENDED BY *

Applicant Authorization

I hereby authorize Jerry Mullen or his designee to select hospital facilities and/or a physician of his choice and authorize treatment of the above named applicant on an emergency basis in the event such treatment becomes necessary.  I will be responsible for all bills incurred as a result of illness or accident while the above named applicant is at Shawnee Mission South High School.  I hereby request you accept the application for enrollment of the above named applicant for the Mullen’s Great Midwest Shootout.  In consideration of your acceptance of this application, I hereby release Jerry Mullen and Shawnee Mission South High School and their employees from all claims on account of injuries, illness or disease which may be sustained by the above named applicant while attending the Mullen’s Great Midwest Shootout and I further agree to indemnify Jerry Mullen and Shawnee Mission South High School for any claim which may hereafter be presented by the above-named applicant as a result thereof.

Applicant's Signature *

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