T.O.P Medical Exemption Form - Injury or Exceptional Circumstance:
This form is to assist athletes whose performances may have been affected by physical or mental injury, pregnancy, or other this past season. This form will help provide supplementary information to the TOP Selection Committee for comprehensive review of the athlete's application to the program. Please fill out this form in addition to the T.O.P Application Form.
Athlete Information
Athlete's Name:
*
First Name
Last Name
Athlete's E-mail:
*
Athlete's Phone Number:
*
-
Area Code
Phone Number
Coach's Name:
*
First Name
Last Name
Coach's E-mail:
*
Coach's Phone Number:
*
-
Area Code
Phone Number
Club Affiliation:
*
A. Medical History
1. Medical Reason you were unable to compete, or unable to compete to the best of your ability (i.e. proximal hamstring attachment tear):
*
2. Please describe the nature of this injury or exceptional circumstance (i.e. what happened, when etc.):
*
3. In what event(s) do you compete in?
*
4. What were your marks in the indoor season prior to your injury / exceptional cirumstance:
*
Rows
Date
Event Name
Mark
Competition #1
Competition #2
Competition #3
Competition #4
Competition #5
Competition #6
5. What were your marks in the outdoor season prior to your injury / exceptional circumstance:
*
Rows
Date
Event Name
Mark
Competition #1
Competition #2
Competition #3
Competition #4
Competition #5
Competition #6
6. Upload letter from a Certified Medical Doctor or equivalent professional indicating diagnosis, rehabilitation plan, and prognosis for recovery:
*
Upload a File
Cancel
of
B. Competition Concerns
1. Please provide rationale on why this circumstance impacted your ability to compete this season:
*
2. Upload any relevant supporting documents (letter from coach, etc.):
Upload a File
Cancel
of
C. Other
(Bevearement, compassionate grounds, etc.)
1. Please describe the impact of this circumstance, and why you would still like to be considered for TOP Athlete Development Program selection for the 2023-2024 season:
*
2. Upload any relevant supporting documents (i.e. letter from parent etc.):
Upload a File
Cancel
of
Athlete's/Parent (if athlete is under 18 year of age) E-Signature attesting to the truth of this information provided:
*
Date:
*
-
Month
-
Day
Year
Date Picker Icon
Submit
Should be Empty: