Name :_______________________________________

Current address:_______________________________

____________________________________________

Telephone Number:_______________________________

Father's Name: ______________________

Mother's Name: ______________________

Insurance Carrier/Policy Number:_______________________________

High School/College/University Name: ______________________

Address:_______________________________

____________________________________________

Telephone Number:_______________________________

Coach's Name:_______________________________

Telephone Number:_______________________________

E-mail Address:_______________________________

Total Years Cheered:_______________________________

Tumbling Skills:_______________________________

Circle One: Base Flyer Both

ACT Score:_______________________________

SAT Score:_______________________________

Cumulative GPA:_______________________________

College Major:_______________________________

Shepherd University Department of Athletics

Attention: Cheer Coach

P.O. Box 3210

Shepherdstown, WV 25443