Care Package Request Form

Your Name *

Please indicate name of the person requesting the care package on behalf of the sidelined athlete. (If you are the athlete, type your name.)

First Name

Last Name

In relation to the athlete, I am their: *

Athletic Trainer

Coach

Parent

Teammate

Friend/Family Friend

Other

Self (I am the sidelined athlete)

I verify that the athlete is between 13-23. *

Yes

No

I verify that the athlete has experienced a *permanent* medically-forced exit from sport within the past 12 months. *

Yes

No

I have permission from the athlete to send a care package via Sidelined USA. (Including permission to supply mailing address.) *

Please note, permission is required.

Yes

No

I am the athlete and am giving permission

Name of Athlete *

First Name

Last Name

Care Package Customization:

(Optional) Please check any that apply to the athlete's experience as a medically-disqualified athlete and we will customize the materials to provide a more personalized box. (If HIPAA applies, please get permission to disclose.)

Jr. High Athlete

High School Athlete

Collegiate Athlete

Athlete had Professional or Olympic Aspirations

Concussion(s)

Career-ending Injury

Repeat Injuries

Health Condition Diagnosis

Mental Health Struggles

Chronic Illness

Baseball

Basketball

Football

Gymnastics

Ice Skating

Lacrosse

Soccer

Softball

Track/Cross Country

Other Sport

T-shirt Size *

Womens MED

Womens XL

Mens M

Mens L

Mens XL

Mens XXL

Mens 3XL

Please indicate wristband size *

SM, MED, or LRG (fits most)

XL (7-8 inches *Recommended for athletes 200lb.+)

Mailing Address *

**Please indicate where to send the athlete care package. →INCLUDE C/O "YOUR NAME" on Address Line 1 if sending to yourself to give to the athlete.←

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country