URMC / Orthopaedics and Rehabilitation / Patient Care / Appointment Request / Specialty Programs Registration Form Specialty Programs Registration Form Athlete's Information First Name Last Name Gender MaleFemale Age If under the age of 18 years old, please provide the name(s) of your Parent(s). Mother's Name Father's Name School Name Primary Sport Played Please Select your Primary Sport Baseball Basketball Cheerleading Cross Country Field Hockey Football Golf Gymnastics Hockey Lacrosse Indoor Track and Field Outdoor Track and Field Racquetball Skiing Soccer Softball Squash Swimming & Diving Tennis Ultimate Frisbee Volleyball Wrestling Other ** Other Participating Sport(s) Baseball Basketball Cheerleading Cross Country Field Hockey Football Golf Gymnastics Hockey Lacrosse Indoor Track and Field Outdoor Track and Field Racquetball Skiing Soccer Softball Squash Swimming & Diving Tennis Ultimate Frisbee Volleyball Wrestling Other ** Use ctrl+click to select any/all that apply Street Address City State Zip Code Phone (Work) ( ) - Second three digits Last four digits Phone (Cell) ( ) - Second three digits Last four digits Email address Emergency Contact Information Contact Name Phone (Work) ( ) - Second three digits Last four digits Phone (Cell) ( ) - Second three digits Last four digits Primary Care Physician (only if referral needed) Provider Name Office Phone ( ) - Second three digits Last four digits Athletic Performance Training Services Testing Options Movement Analysis $75.00 $0.00 VO2 Analysis and Fitness Testing VO2 Analysis $190.00 $0.00 Resting Metabolic Rate (RMR) Testing $190.00 $0.00 Athletic Performance Sessions 24 Sessions $408.00 $0.00 36 Sessions $540.00 $0.00 48 Sessions $624.00 $0.00 Trial 5 Sessions $160.00 $0.00 1 Session $32.00 $0.00 A La Carte Sessions Sports Nutrition Initial Evaluation $75.00 $0.00 Sports Nutrition Follow-Up$45.00 per session. Number of sessions = $45.00 $0.00 Mental Skills Initial Evaluation $50.00 $0.00 Mental Skills Follow-Up$35.00 per session. Number of sessions = $35.00 $0.00 Custom (Team) Training ProgramDollar amount from quote = $ QUOTE $0.00 Total: $0.00