Neurological Care Application

WSF Neurological Care Application
Thank you for taking the time to complete this application.

Thie information you share helps our neurological care team better understand what you've been experiencing and determine the most appropriate next steps for your evaluation and care.

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 (if applicable)
  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. Additional detailed questionnaires maybe be required to help determine best next steps for your care.

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 coordinate any care you are approved for.
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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Current Symptoms & Injury Detail
Please describe the type of issue you are experiencing.

Other
Please describe your injury or symptoms
If this is a new injury please name of the event where your injury occurred
Upload Doctor Certificate if applicable - 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 Neurological Care Application

General Information

Professional Affiliation

Current Symptoms & Injury Detail

Secondary Contact Information