Athletic Performance and Injury Prevention Registration Form

Athlete's Information
First Name Last Name
Gender Male      Female 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

Other Participating Sport(s)

Use ctrl+click to select any/all that apply

Street Address City
State Zip Code
Phone (Work) Phone (Cell)
Email address

Emergency Contact Information
Contact Name
Phone (Work) Phone (Cell)

Primary Care Physician (only if referral needed)
Provider Name Office Phone
Athletic Performance Training Services
Testing Options
  Movement Analysis $75.00
  VO2 Analysis and Fitness Testing
  VO2 Analysis $150.00
  Resting Metabolic Rate (RMR) Testing $150.00

Athletic Performance Sessions
  24 Sessions $408.00
  36 Sessions $540.00
  48 Sessions $624.00
  Trial 5 Sessions $160.00
  1 Session $32.00

A La Carte Sessions
  Sports Nutrition Initial Evaluation $75.00
  Sports Nutrition Follow-Up $35.00 per session. Number of sessions =
$0.00
  Mental Skills Initial Evaluation $50.00
  Mental Skills Follow-Up $35.00 per session. Number of sessions =
$0.00

Custom (Team) Training Program Dollar amount from quote = $
$0.00


 

Total : 0.00