Naugatuck Valley Community College

Athletic and Recreational Sport Application

Circle the sport or sports you are interested in:

(Men’s Baseball) (Women’s Softball) (Women’s Basketball) (Men’s Basketball)
(Co-ed Soccer) (Co-ed Volleyball) (Co-ed Cheerleading)

Name: __________________________________

Social Security Number: ________________________

Student Id: ___________________________________

Address: _____________________________________

City & State: __________________________________

Telephone(s): (home)______________________(cell/pager)________________________

Age _______ Wt. _________ Ht. ___________

Emergency Contact: ____________________________________________

List any medical concerns: _______________________________________

List any athletic experience you have had: ___________________________

Return to: Lucy Ann Hurston, Director of Athletic and Recreational Sports (K601)