CSCM Athlete Intake Form

CSCM Athlete Intake Form

History with COPSIN
Have you previously been associated with another Canadian Sport Centre or Institute?*
If yes,
Which one(s)?

Canadian Sport Centre AtlanticCanadian Sport Centre SaskatchewanCanadian Sport Institute CalgaryCanadian Sport Institute OntarioCanadian Sport Institute PacificInstitut National Du Sport Du Québec
Were there specific service providers you worked with at the above centre(s)/institute(s)?
If yes, please provide their names, emails & areas of practice
Can we contact the above provider(s) to gather information on the work you have done?

CSCM Athlete Intake Form

Athlete Medical Information - NOTE this information is kept confidential
Emergency Contact*

First NameLast Name
Relation*
Primary Phone*

Area CodePhone Number
Team/Family Doctor*

First NameLast Name
Have you had a physical in the last 12 months?*
Do you have any injuries or health issues our staff should be aware of (including mental health)?*
If yes, please elaborate

CSCM Athlete Intake Form

Sport Information
Primary Team/Club*
Primary Coach*

First NameLast Name
Coach's Phone*

Area CodePhone Number
Coach's E-mail*
Are you Sport Canada Carded?*
Yes
What level of carding do you have?
Are you registered with Game Plan?
No? Please take a look at the Game Plan website (http://mygameplan.ca) and consider registering. Contact Stephanie Lambert (stephanie@cscm.ca) with any questions
No, but have been previously
When were you last carded?

MonthDayYear
What level were you last carded at?
Why was your carding not renewed?

CSCM Athlete Intake Form

Athlete Centered, Coach Driven, Expert Resourced
CSCM will work together with your coach to develop the most effective integrated plan for optimal performance.

With that in mind...
What are you hoping to get out of a relationship with CSCM?*
What does your coach/NSO think would benefit you most at this time?*
Do you or your coach have any concerns about working with CSCM?*
If yes, please elaborate
CSCM Athlete Intake Form

Life Outside of Sport
CSCM values you as a whole person, not just as an athlete
Are you presently in school?*
If yes,
Would you like assistance/resources to explore education opportunities?
Are you presently employed?*
If yes,

CSCM Athlete Intake Form

Under 18 years of age? Please fill out this section
Parent / Legal Guardian A

First NameLast Name
Address - if different from Athlete's primary

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Primary Phone

Area CodePhone Number
Parent / Legal Guardian B

First NameLast Name
Address - if different from Parent / Legal Guardian A's

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail - if different from Parent / Legal Guardian A's
Primary Phone - if different from Parent / Legal Guardian A's

Area CodePhone Number