SurveyMonkey Powered Online Survey

Thank you for your interest in Athletic Training services provided by St. Luke's University Health Network. SLUHN values the opportunity to enhance relationships with local schools, clubs, and other organizations.

Please complete the following form and an Athletic Training representative will be in touch with you to discuss your medical service needs. We suggest providing as much lead time as possible to allow for proper planning and staffing. You will be contacted within 72 hours following your request. Thank you!

For questions or assistance, e-mail Stephenie Stark @ stephenie.stark@SLUHN.org.

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* 1. Organization Information

Organization Name *

Address *

Address (if necessary)

City/Town *

State/Province *

ZIP/Postal Code *

Phone Number *

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* 2. Type of Organization

Special Event/Tournament

School District (Elementary, Middle, High School)

College/University

Club

Other (please specify)

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* 3. Applicant Information

Name

Title

Phone Number

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* 4. State(s) Where Coverage Will Occur

Pennsylvania

New Jersey

Other (please specify)

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* 5. Type of Event

Baseball

Baskeball

Cheerleading

Football

Gymnastics

Hockey

Lacrosse

Rugby

Soccer

Track/Cross Country

Wrestling

Volleyball

Other (please specify)

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* 6. Participant Demographics

Ages 5-8

Ages 9-12

Ages 13-17

Ages 18+

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* 7. Type of Service / Coverage

One Time Event / Coverage - Complete question #8

On-going Services - Please specify dates and needs (Do not need to complete #8)

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* 8. Event Details

Start Date/Time

Date

Time

AM/PM

End Date/Time

Date

Time

AM/PM

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* 9. Number of Games to be Covered

Other (please specify)

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* 10. Number of Athletic Trainers Requested

Other (please specify)

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* 11. Venue Information

Name *

Address *

Address (if necessary)

City/Town *

State/Province *

ZIP/Postal Code *

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* 12. On-Site Contact Information - Day of Event

Name

Email Address

Phone Number

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* 13. On-Site Supplies Available

Tent

Ice

Coolers

AED

Golf Cart

Tables

None

Other (please specify)

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* 14. How Did You Hear About our Athletic Training Services?

Email communication

Social media

Website

St. Luke's employee

Other (please specify)

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* 1. Organization Information

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* 2. Type of Organization

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* 3. Applicant Information

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* 4. State(s) Where Coverage Will Occur

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* 5. Type of Event

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* 6. Participant Demographics

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* 7. Type of Service / Coverage

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* 8. Event Details

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* 9. Number of Games to be Covered

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* 10. Number of Athletic Trainers Requested

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* 11. Venue Information

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* 12. On-Site Contact Information - Day of Event

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* 13. On-Site Supplies Available

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* 14. How Did You Hear About our Athletic Training Services?

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* 15. Other Pertinent Details Regarding Event