WSF Catastrophic Financial Assistance Application

WSF Catastrophic Financial Assistance Application
Thank you for taking the time to complete WSF's Catastrophic Financial Assistance Application. We understand that navigating injury and recovery can feel overwhelming, and our goal is to make this process as clear and supportive as possible. This application should take between 5-15 minutes to complete.

To help the process go smoothly, please be prepared to upload the following required documents in order to submit your application:
- A copy of your current professional or affiliation card
- A copy of a doctor’s certificate detailing the recommended treatment and anticipated time away from competition
  The doctor’s certificate must be dated, include the applicant’s name, and be provided on the physician’s official letterhead.
Please know that all information shared through this form is treated as confidential and is protected in accordance with HIPAA privacy standards.

If you have questions at any point or need assistance completing the application, our team is here to support you.
General Information

The following will be used to help us contact you and mail you any approved financial assistance payments.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth - Month/Date/Year
Gender
Professional Affiliation
Please indicate the events you compete in:
Please indicate the organizations you hold a card with:
Please upload a copy of your Affiliation Card (ex: PBR, PRCA, NIRA)

.pdf, .jpeg or .png file format only
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About your injury
Name of the event where your injury occurred
Location of event
Date of event
Was Hospitalization Required?
If you answered YES, please state how long you were hospitalized.
Was Surgery Required?
If you answered YES, please indicate your surgery date.
Please describe your injury
Upload Doctor Certificate - this is a document that describes recommended treatment and anticipated time away from competition.

Document must be dated, on Doctor letterhead andm include the Athlete Name. .pdf, .jpeg or .png file format required.
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Secondary Contact Information

Please share a trusted secondary contact that Western Sports Foundation (WSF) may communicate with on your behalf. This may include discussing sensitive information, helping with application questions, and supporting your ongoing care and resource coordination.
Secondary Contact Name

First NameLast Name
Secondary Contact Email
example@example.com
Secondary Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Your relationship with Secondary Contact
Should be Empty:

WSF Catastrophic Financial Assistance Application

General Information

Professional Affiliation

About your injury

Secondary Contact Information