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Athletic Training Coverage Application

We would love to hear from you! Please fill out this form and we will get in touch with you within 72 hours.

Step 1 of 2

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Type of Organization*
Do you have a deadline (to confirm staff availability/obtain a quote for services)?*
- Yes
- No
Deadline*
MM slash DD slash YYYY

Please note that we request your application be submitted at least 6 weeks in advance of this deadline in order to provide a final decision regarding your application.
Organization Name*
Name of Applicant*
First Last
Applicant Email*
Title*
Information for invoicing (what appears on contract for services, ie. Representative authorized to sign off on contract)
Name of Signer
First Last
Title*
Email*
Phone*
Address*
Street Address Address Line 2 City State ZIP Code
Organization website
State(s) where coverage will occur*
- Arizona
- Illinois
- Indiana
- Iowa
- Kansas
- Michigan
- Mississippi
- Missouri
- Nebraska
- Ohio
- South Dakota
- Texas
- Wisconsin

How did you hear about our athletic training services?*
- On-site at another event
- Email communication
- Social media
- Website
- Co-worker
- Athletico employee
- Other
Please specify other*
Have you applied for coverage within the last 12 months?*
- Yes
- No
If Yes, please choose date you applied*
MM slash DD slash YYYY
Approximate # of coverage hours needed per week (Fall Season)
Approximate # of coverage hours needed per week (Winter Season)
Approximate # of coverage hours needed per week (Spring Season)
Approximate # of coverage hours needed per week (Summer Season)
Process for contract approval*
- Bid process
- Request for proposal
- Other
Please specify other*
Please select the type of event. (check all that apply)*
- Football
- Soccer
- Volleyball
- Baseball
- Basketball
- Hockey
- Rugby
- Wrestling
- Lacrosse
- Gymnastics
- Cheerleading
- Track/Cross Country
- Other
Please specify other*
Number of Participants/Enrollment*
Name of Event*

Please list the name of your event
Description of Event*
Number of days for event*
- 1 day
- 2 days
- 3 days
- more than 3 days
Day of Coverage*
MM slash DD slash YYYY
Start Time of Coverage*

: Hours

Minutes

AM/PM
End Time of Coverage*

: Hours

Minutes

AM/PM
Day 2 of Coverage*
MM slash DD slash YYYY
Start Time of Coverage*

: Hours

Minutes

AM/PM
End Time of Coverage*

: Hours

Minutes

AM/PM
Day 3 of Coverage*
MM slash DD slash YYYY
Start Time of Coverage*

: Hours

Minutes

AM/PM
End Time of Coverage*

: Hours

Minutes

AM/PM
Dates & Times of Coverage*
Dates & Times may be uploaded via file
Max. file size: 20 MB.
Number of venues for event*
- 1 venue
- 2 venues
- 3 venues
- more than 3 venues
Indoor/Outdoor Venue?*
- Indoor
- Outdoor
1. Event Venue Name*
Event Venue Address*
Street Address Address Line 2 City State ZIP Code
Number of Courts/Fields*
Indoor/Outdoor Venue?*
- Indoor
- Outdoor
2. Event Venue Name*
Event Venue Address*
Street Address Address Line 2 City State ZIP Code
Number of Courts/Fields*
Indoor/Outdoor Venue?*
- Indoor
- Outdoor
3. Event Venue Name*
Event Venue Address*
Street Address Address Line 2 City State ZIP Code
Number of Courts/Fields*
Please list details about multiple venues (indoor/outdoor, names, addresses, number of courts/fields, etc.)*
Multiple venue details may be uploaded via file
Max. file size: 20 MB.
Number of ATs requested (per day/shift)*
Parking available on site?*
- Yes
- No
Reimbursement for parking?*
- Yes
- No
Years in Existence (event)*
Frequency of Event
Where are the event guest/participants from?
What is the age range of guests/participants? (check all that apply)*
- Youth (0-5 yrs)
- Youth (5-10 yrs)
- Youth (10-13 yrs)
- Middle School
- High School
- College
- Adult
On Site Contact Person Name*
First Last
On Site Contact Person Email*
On Site Contact Person Cell Phone #*
On Site Supplies Available (check all that apply):*
- Tent
- Ice
- Coolers
- AED
- Golf Cart
- Table
- Other
- None
These supplies are on site and available for Athletico's use
Please Specify Other*
Please upload W-9 form
Max. file size: 20 MB.
Please upload a W-9 form if applicable
- By clicking this box you agree to receive email communication from Athletico Physical Therapy

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Athletico Physical Therapy complies with applicable Federal civil rights laws and does not discriminate on the basis of race, age, religion, sex, national origin, socioeconomic status, sexual orientation, gender identity or expression, disability, veteran status, or source of payment. You will be treated with dignity, compassion, and respect as an individual.

Athletico Physical Therapy cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, edad, religión, sexo, origen nacional, condición socioeconómica, orientación sexual, identidad o expresión de género, discapacidad, condición de veterano o fuente de pago. Serás tratado con dignidad, compasión y respeto como individuo.

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