Basketball Intensive Application Page 1 (HIPPA Compliant)

Origins Basketball Experience Application
Name*

First Name Last Name
Email*
example@example.com
Phone Number*
Birthday*

MonthDay Year
Date
Gender*

MaleFemale
What is your role?*

PlayerCoach
Shirt/Hoodie Size*
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Marital Status*
Will your spouse be attending with you?*

YesNo
Do you have minor children?*

YesNo
Will your children be attending with you?*

YesNo
Education Information
Highest Level of Education Completed*
Name of High School/ University*
Level of Basketball Experience*
(ex. College Level )
What languages do you speak?*
(most fluent to least)
Additional Information
Country of Birth*
Country of Citizenship*
Will you be opting in for the international outreach? (10-14 days additional cost)*

YesNo
Do you hold a valid passport?*

YesNo
Passport Expiration Date*

MonthDay Year
Date
Reference Information
Reference Full Name*
First and Last Name
Reference Phone Number*
Reference Email*
Relationship to Applicant*
EX) Pastor, Leader, or Mentor
Personal Questions
Why do you want to do the Origins Basketball Intensive?*
Please note, sensitive information should not be included in this response.
How did you hear about the Origins Basketball Intensive?*
Please note, sensitive information should not be included in this response.
How would you describe your current relationship with God?*
Please note, sensitive information should not be included in this response.
Contact Owner*
Program*
Submitted Basketball Application*
Should be Empty:

Origins Basketball Experience Application

Education Information

Additional Information

Reference Information

Personal Questions