Athletic Training Coverage Application

How did you hear about our athletic training services?*

Please specify other*

Have you applied for coverage within the last 12 months?*

Yes
No

If Yes, please choose date you applied*

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)*

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*

Start Time of Coverage*

: HH

MM

End Time of Coverage*

: HH

MM

Day 2 of Coverage*

Start Time of Coverage*

: HH

MM

End Time of Coverage*

: HH

MM

Day 3 of Coverage*

Start Time of Coverage*

: HH

MM

End Time of Coverage*

: HH

MM

Dates & Times of Coverage*

Dates & Times may be uploaded via file

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

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 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

Please upload a W-9 form if applicable

By clicking this box you agree to receive email communication from Athletico Physical Therapy

Comments

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Athletic Training Coverage Application

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