Sports Program Application

Date of Registration(Required)

Athlete Name(Required)

First Last

Athlete Email

Age

Graduation Date(Required)

Sport(Required)

Position

Years Played

School(Required)

Coach Name

First Last

Coach Email

Parent Name(Required)

First Last

Parent Email(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Nationality

Major Area of Study

GPA

Therapist Name

First Last

Trainer Name

First Last

Medications

Prior Injuries

List any setbacks to date(Required)

Reason for Registration/Goal for participation(Required)

Requested Clinician at Care to Change

How you heard about Peak Performance Protocol/Who referred you(Required)

Requested start date(Required)

Requested completion date

Method of payment (options, cash, card, HSA, insurance - if so, name)

Privacy and Confidentiality Notice

Care to Change Counseling Center respects your privacy and is committed to protecting the personal and health information you share with us. Information collected through this registration form will be used to evaluate your participation in the Peak Performance Protocol, coordinate appropriate services, and communicate with you regarding your registration and care. Your information will be accessed only by authorized personnel and will be maintained in accordance with applicable privacy laws and Care to Change's privacy and confidentiality policies. Submitting this registration form does not authorize Care to Change to release your personal or health information to coaches, trainers, schools, parents, or other third parties. Any disclosure requiring your authorization will be addressed through a separate consent process.