Registered Athlete Identification

Full Name:

Sport:

Email Address:

Mailing Address:

City:

Postal Code:

Contact Phone Number:

Contact by Text:
YesNo

If yes, who is your cell service provider (we require this information for email to text communication):

Social Media Handles

Name of Current Coach:

Email Address of Current Coach:

Current Card Level:
Provincial DevelopmentCanadian DevelopmentCanadian ElitePodium

Number of years with PacificSport carding:

List your top 3 goals for the year:

List your top 3 results from the past year:

Please list names of GymWorks, FoodStuff, MoreStuff and SportHealth Partner facilities you regularly use:

Please provide any feedback that can help improve the benefits and programs offered by your Centre:

Indicate your preferred days/times to attend PSVI workshops, seminars & events:

Athlete Agreement
To "Agree" tick a box titled beside each of the following statements:

i. I acknowledge my responsibility to abstain from the use of banned substances as outlined by the Canadian Policy Against Doping in Sport (2011)

ii. I acknowledge my responsibility to be aware of and respect PacificSport VI partners both on and off the field of play

iii. I commit to providing regular updates to PacificSport VI regarding my results and achievements

iv. I give permission for Canadian Sport Institute Pacific/PacificSport to share my permanent address with the Canadian Sport Institute Pacific/PacificSport network of regional centres, Canadian Olympic Committee, Sport Canada, Coaches Association of Canada and the Sport Branch of the Provincial Government

v. I give permission for Canadian Sport Institute Pacific/PacificSport to use photos and/or videos that I appear in to be used for promotional puposes

vi. I give permission to be contacted by electronic messaging regarding Canadian Sport Institute Pacific/PacificSport fund development initiatives, athlete benefits, programs, services, newsletters, performance points and promotional opportunities

I, , as an athlete registered with Canadian Sport Institute Pacific/PacificSport, agree to abide by the Athlete obligations outlined above.

E-Signature of Athlete (named above):

Sport:

E-Signature of Parent/Guardian (if athlete is under 19):

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