Questionnaire

If you are interested in playing in the USHL, please complete and submit this form.

Please provide the information requested below:

Name First Name Middle Initial Last Name

Personal Information Date of Birth Birth Date * Height Height ft in Weight

Are you a US Citizen?

If no, please list your native country

Contact Information E-Mail Address Street Address City State ZIP Code Home Phone Cell Phone

Family Information

Parents Father's Name Father's Occupation

Is your father a college graduate?

If yes, from what university? Mother's Name Mother's Occupation

Is your mother a college graduate?

If yes, from what university?

Siblings Please list any brothers or sisters and their ages

Hockey Information clubteam_ Team clubteam_ League
position 1 position 2 shoots Team Website Coach's Name First Last Coach's Phone Number Coach's Email

Teams you have played with the last three years: Statistics / (Goalies)

Year	Team	GP	G/(GAA)	A/(SV%)	PIMS/(SO)
Year	Team	GP	G/(GAA)	A/(SV%)	PIMS/(SO)
Year	Team	GP	G/(GAA)	A/(SV%)	PIMS/(SO)

Other sports you play or played Honors / Awards received in all sports

Gauge your level of interest in playing for a USHL team next season
Some Maybe Most Likely Definitely

Do you have a family advisor?

If yes, which company/agency? Family advisor's name Family advisor's phone number

Are you on the protected list of a Canadian Major Junior team?

If yes, which one?

Academic Information

School State

School Name		School Address
School City		School ZIP
School Phone		School Fax #
Coach First		Coach Last
Coach Home Phone
Coach Cell Phone		Coach Email

What grade are you in? Year of Graduation Guidance Counselor Counselor's Phone Number Your Grade Point Average or Percentage Your Class Rank ACT Composite Score

SAT Scores:
Math	Verbal	Written

Have you applied to and had your core classes approved by the NCAA Clearing House? Your desired College Major

Additional Information

Rate your opponents:

Best Forward	Team
Best Defenseman	Team
Best Goalie	Team

Repeat the code below: