Athlete's Registration Form
Provide your consent for the movement screening and related activities.
Athlete age status
*
Athlete is 18 years and older
Athlete is under 18 years old
Parent's Full Name (if athlete is under 18 years old)
First Name
Last Name
Athlete's Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Is your athlete currently recovering from an injury?
Yes
No
Consent Statements
*
I consent to a video analysis movement screening by a licensed physical therapist.
I understand that recordings may be used for promotional education or publicity purposes including website, social media and marketing without expected compensation. I can choose to opt out of use, in writing, at any time.
I agree to receive the screening report.
I understand this is not a medical treatment or diagnosis
Submit Consent
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