CSCM Athlete Intake

Parent / Guardian Information

General Information

Primary Address *
Primary Address
City
State/Province
Zip/Postal
Country
Ex. Calgary, Alberta or Canadian Sport Centre Calgary
6-Digit Number
9-Digit Number

Emergency Contact Information

Sport Information

Ex. Soccer,Taekwondo, Diving
Ex. Diving Training Group, Rowing Manitoba Training Group, Etc.
Carding Status *
If unsure, please select 0.
If unsure, please select 0.

Game Plan

Plans for Career, Education, Personal Development, Etc.

Employment

Nutrition

Mental Health & Wellness

(1= Never; 3=Sometimes; 5=Always)
(1= Never; 3=Sometimes; 5=Always)
(1= Never; 3=Sometimes; 5=Always)
(1= Never; 3=Sometimes; 5=Always)
(1= Never; 3=Sometimes; 5=Always)
Example: Challenging life events, prior experience with counselling , family history of mental illness, difficult experience in sport, etc

Physical Preparation & Training History

Example (Weights, Dry-Land, Etc.)
Frequency, Training Types, Time, Etc

Current Injury Status

Please list any current injuries we should be aware of.

Injury History

Please list your past injuries.

Service Providers

Please list your primary service providers names and contact information below.
Dr. John Smith
204-123-4567
john.smith@physician.com

Tell Us More About Yourself

Social Media

Please provide us with your social media information. Instagram, Twitter, Youtube, Facebook, LinkedIn, Etc

Additional Information

Review & Submit

I Agree, all the information given in this application is complete and true. *
I Agree, The Canadian Sport Centre Manitoba is authorized to verify any information contained in this application. *
I Agree, to be contacted via Email, Text (SMS) , and other communication methods by the Canadian Sport Centre Manitoba. *
I Agree, the Canadian Sport Centre Manitoba is authorized to contact my coach in my respective sport. *
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