Legal Name:  Last    First 
Middle Initial
Social Security Number:
Email Address:
Birthdate:    Phone:
Mailing Address:   Street 
City      State       Zip 
Country:
Parent(s) Name:

Times:  1500/1600:    3000/3200:   
              5K:      10K:     
          
Height:  Weight:   
State Meet Qualification In:   
Coach:    Coach's Phone:
Coach's Email Address: 
Athletic Honors Received:
 
Other Athletic Interests:
     
   

Name of your High School:   
School Address: Street 
City      State       Zip 
Cumulative Grade Point:    Class Rank(# out of #):   
ACT Score: (if available) 
Graduation Date and Year:   
School Phone: 
Academic Interest Area(s): 

Name/Signature:   Date: 

You may choose to submit this application electronically, or by mail, to:
Molly Struve, Cross Country Coach
300 South 18th Street
Estherville, IA 51334-2725