Availables One Day Showcase, Saturday, July 11, 2009

Mullen’s Great Midwest Shoot-out, Saturday, March 21, 2015 Shawnee Mission South High School 5800 West 107th Street – Overland Park, KS 66207 **Check-In 8:45 am to 9:45 am**

Pre-Registration REQUIRED – $75/entry fee +$3.00 processing fee Please complete ALL blanks and e-mail to: [email protected]

Full Name: Home Pho: ( ) Cell Pho: ( )

HOME Address: City: ST:

Zip: Ht: Wt: GPA: ACT/SAT:

Current Class in School: (HS Senior, Post-Grad, JC Freshman, JC Sophomore):

YOUR E-mail Address:

Twitter: @ POS 1: POS 2:

Add’l info that could assist you in your recruitment:

Awards/Accomplishments:

Years of Remaining Eligibility: Credit Hrs Earned: Coach’s Name:

Coach’s School Phone: ( ) Coach’s Cell Phone: ( )

Coach’s Email:

Health Insurance Co: Insured’s Name:

Policy #: Group #: Insurance Company Phone: ( )

Recommended by:

APPLICANT AUTHORIZATION: I hereby authorize Jerry Mullen or his designee to select hospital facilities and/or a physician of his choice and authorize treatment of the above named applicant on an emergency basis in the event such treatment becomes necessary. I will be responsible for all bills incurred as a result of illness or accident while the above named applicant is at Shawnee Mission South High School. I hereby request you accept the application for enrollment of the above named applicant for the Mullen’s Great Midwest Shootout. In consideration of your acceptance of this application, I hereby release Jerry Mullen and Shawnee Mission South High School and their employees from all claims on account of injuries, illness or disease which may be sustained by the above named applicant while attending the Mullen’s Great Midwest Shootout and I further agree to indemnify Jerry Mullen and Shawnee Mission South High School for any claim which may hereafter be presented by the above-named applicant as a result thereof.

Applicant’s Signature: