First Name: Middle Name: Last Name:

Male: Female:

Sports participating in at Thiel:

Cell phone number: Home phone number:

E-mail address: AOL screen name:

Home Address: Street

Home Address: City, State & Zip Code

Campus address:

High school: Year of high school graduation:

City, State of high school:

Sports you participated in while in high school:

High school athletic honors and accomplishments:

High school academic honors and accomplishments:

Membership in clubs or organizations:

Relatives who have attended Thiel College:

Are you married? Yes No             If so, name of spouse:

Father's Name:

Mother's Name:

Address: Street

Address: City, State & Zip Code

Do your parents live at the same address? Yes No  If not, please list parent and separate address:

Names of hometown newspapers (Please include addresses and/or city if possible)

I, , understand that my name, information, and photo may be released to the public. If you do not want this information used for publicity purposes, please do not check box.

I, , authorize Thiel athletic department administrators to release my GPA and other academic-related information when needed to nominate me for academic/athletic awards.
If you do not want this information used for such purposes, please do not check box.