*Mailing Address 
*City     *State     *Zip Code
*Phone 
*E-mail Address 
Date of Birth  (MMDDYY)

Date of High School Graduation  (MMDDYY)
Parent/Guardian Name 

SCHOLASTIC INFORMATION
High School 
City     State     Zip Code
School Phone 

Head Coach: Phone:

Have you applied for Financial Aid? Yes   No
Desired Course of Study:
Other Sports You Have Participated In:

ATHLETIC INFORMATION
Position(s) Played:
Offense: 
Defense: 

Height:    Weight: lbs.
Bench Press: lbs.  Leg Press/Squat: lbs.  40-yard dash:

Special Teams:
Honors & Awards:

Do you have any injuries requiring medical attention? Yes   No
If Yes, please describe:

Is film/video on you available to view? Yes   No
Jersey Number:

"I hereby certify that I made First Contact with Los Medanos College and that I am requesting information from this college without prior contact by members of the staff or persons representing Los Medanos College."
Yes*

Additional Background Information:

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