CSCM Athlete Intake

Are you 18 years or older? *

Parent / Guardian Information

Name of Parent/Guardian *

Email of Parent/Guardian *

Phone Number of Parent/Guardian *

General Information

First Name *

Last Name *

Date of Birth *

Sex Assigned At Birth

Home Province *

Primary Address *

Primary Address

City

State/Province

Zip/Postal

Country

Primary Phone Number *

Primary Email *

Are you a Manitoba resident? *

Yes

No

Where are you visiting from? *

Ex. Calgary, Alberta or Canadian Sport Centre Calgary

Manitoba Health Registration Number *

6-Digit Number

Personal Health I.D. Number *

9-Digit Number

Emergency Contact Information

Emergency Contact Name *

Relation *

Emergency Contact Phone Number *

Sport Information

Sport *

Ex. Soccer, Taekwondo, Diving

Are you currently involved in a Training Group or Integrated Support Team in partnership with the Canadian Sport Centre Manitoba? *

Ex. Diving Training Group, Rowing Manitoba Training Group, Etc.

Which training group are you involved in? *

Carding Status *

Senior International Card (SR1/SR2)

Senior National Card (SR)

Senior Probationary Card (C1)

Development Card (D)

D-Regional (D-Reg)

National Development Team Athlete (Not Carded)

Currently Not Carded or On National Development Team

At what level do you currently compete in? *

Current Organization/Team *

Current National Rank *

If unsure, please select 0.

Current World Rank *

If unsure, please select 0.

Primary Coach Name *

Primary Coach Phone Number *

Primary Coach Email *

Game Plan

Do you have any non-sport plans or goals for the future? *

No

Yes

Plans for Career, Education, Personal Development, Etc.

Tell us about your plans and/or goals. *

Would you be like to be invited to Game Plan Online Sessions & other COPSIN workshops?? *

Select the areas that you would be interested in learning more?

Employment

Are You Currently Employed? *

No

Yes

Current Employer: *

Position: *

Number of hours worked per week: *

Describe your typical week (including training schdule): *

Nutrition

Have you worked with a Sport Dietitian / Nutritionist previously? *

No

Yes

Did you work with a Sport Dietitian / Nutritionist in a group setting or individually? *

Individual

Group

Do you have any specific goals or issues that you would like to discuss with a CSCM Sport Dietitian? *

No

Yes

Please explain your goals and/ or issues you would like to discuss? *

Which of the following nutrition-related goals are you interested in working on? *

What are the other nutrition-related goals are you interested in? *

Have you intentionally or unintentionally had a change in your weight over the past 2 - 3 months?

Increased

Decreased

No, I have not (Stable)

Unsure

Mental Health & Wellness

Have you worked with a Sport Psychologist in the past? *

No

Yes

What did you find most helpful speaking with a Sport Psychologist? *

What did you find least helpful speaking with a Sport Psychologist? *

Do you have interest working with a Sport Psychologist at CSCM? *

No

Yes

Tell Us Why? *

Are there any areas of health and wellness impacting your mental outlook, emotions and/or performance?

No

Yes

If possible, please describe as best as you can.

What are some of your mental strengths? *

What are some of the mental skills you would like to improve on?

In general, what do you enjoy the most about participating/competing in sport? *

How often do you feel Restless or Fidgety?

(1= Never; 3=Sometimes; 5=Always)

How often do you feel Worthless?

(1= Never; 3=Sometimes; 5=Always)

How often do you feel Depressed

(1= Never; 3=Sometimes; 5=Always)

Is there any additional information you believe would be helpful for the sport psychologist to know?

Example: Challenging life events, prior experience with counselling , family history of mental illness, difficult experience in sport, etc

Physical Preparation & Training History

Have you done any formal training?

No

Yes

Example (Weights, Dry-Land, Etc.)

Where and with whom, did you complete your training? *

How many years have you been using these types of training? *

Describe your last three weeks of training? *

Frequency, Training Types, Time, Etc

Current Injury Status

Please list any current injuries we should be aware of.

Are you currently recovering from an injury?

No

Yes

Please describe your current injury. *

Have you had any injuries and or illness in the past 6-12 months that have restricted your training for a week or longer?

No

Yes

What was your injury/illness and how long was your training load compromised for? *

Injury History

Please list your past injuries.

Is there any past injuries CSCM should know about?

No

Yes

Date Of Injury *

Description of injury & how it was managed/treated? *

Add Remove

Service Providers

Please list your primary service providers names and contact information below.

Do you have a Physician? *

No

Yes

Name Of Physician *

Dr. John Smith

Physician Phone Number *

204-123-4567

Physician Email Address *

john.smith@physician.com

Do you have a Physiotherapist / Athletic Therapist? *

No

Yes

Name Of Physiotherapist / Athletic Therapist *

Physiotherapist / Athletic Therapist Phone Number *

Physiotherapist / Athletic Therapist Email Address *

Do you have a Chiropractor? *

No

Yes

Name of Chiropractor *

Chiropractor Phone Number *

Chiropractor Email *

Do you regularly use the services of a chiropractor? *

No

Yes

Do you have a Osteopath Provider? *

No

Yes

Name of Osteopath Provider *

Osteopath Provider Phone *

Osteopath Provider Email *

Do you have a Massage Therapist? *

No

Yes

Name of Massage Therapist *

Massage Therapist Phone *

Massage Therapist Email *

Do you regularly use the services of a Massage Therapist? *

No

Yes

Do you have a Naturopathic Provider? *

No

Yes

Name of Naturopathic Provider *

Naturopathic Provider Phone *

Naturopathic Provider Email *

Tell Us More About Yourself

Applicants Short-Term Sports Goals *

Applicants Long-Term Sports Goals *

Why do you want to become a CSCM Athlete? *

Do you have a bio hosted on the COC/CPC or your NSO/PSO website? If so, please link it here.

Note - this link may be shared as part of an online CSCM bio. If you have more than one bio link, please indicate which one you prefer we share.

Social Media

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

Platform

Username/Handle

Profile URL

I agree to allow CSCM to share this information.

Yes, you can share or post this.

No, please keep this private.

Add Remove

Headshot / Photo

If you have one, please submit a recent headshot and/or action image. Please indicate whether you give CSCM permission to use these photos (including, but not limited to on the website, in promotional materials, on social media, etc). Please only submit images that you have the rights/permissions to share.

Headshot

Maximum upload size: 5MB

Action Image

Maximum upload size: 5MB

Please indicate whether you give CSCM permission to use these photos.

Yes, CSCM can use this image online and in print.

No, CSCM cannot use my images.

Additional Information

Tell us here!

Review & Submit

I Agree, all the information given in this application is complete and true. *

I Agree

I Agree, The Canadian Sport Centre Manitoba is authorized to verify any information contained in this application. *

I Agree

I Agree, to be contacted via Email, Text (SMS) , and other communication methods by the Canadian Sport Centre Manitoba. *

I Agree

I Agree, the Canadian Sport Centre Manitoba is authorized to contact my coach in my respective sport. *

I Agree

Captcha

Parent / Guardian Information

General Information

Emergency Contact Information

Sport Information

Game Plan

Employment

Nutrition

Mental Health & Wellness

Physical Preparation & Training History

Current Injury Status

Injury History

Service Providers

Tell Us More About Yourself

Social Media

Headshot / Photo

Additional Information

Review & Submit

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