INSTRUCTIONS for MEDICAL TEAM APPLICATION FORM

Completed application forms MUST BE TYPED. In order to make it easier for you to complete this form electronically the fields have been set up so you just have to click the appropriate boxes. Tabbing through the document is the easiest way to navigate all the fields.

The application form must be completed IN FULL. Your CV will only be used if requested by the Games organizers. The SPC Selection Team will NOT receive/reference your CV for information. The information from attached CV’s and other documents must be appropriately summarized in the application form in order to receive full credit from the Selections Team. Be sure to complete every applicable box possible to ensure a maximum score.

All relevant forms and documents must be received at the SPC National Office by the respective deadline date; forms which arrive after the posted date will under no circumstance be viewed as eligible for the current Game(s) application(s).

Application Submission Information for:

2016 Olympic Games- Rio, Brazil

2016 Youth Olympic Games- Lillehammer, Norway

DEADLINE: 11:59pm EDT June 30th, 2015
Please E-mail your Application Form with one of the following subject lines:

“Games Application- Both Olympic Games and Youth Winter Olympics”

“Games Application- Olympic Games”

“Games Application- Youth Winter Games”

All applications must be submitted directly to Ashley Lewis by the deadline. ()

GAMES APPLICATION FORM

* DIPLOMAS HOLDERS ONLY*

Health & Science Team Application Form

Please indicate which games you are applying to:

CHIEF THERAPIST: 2016 Olympic Games- Rio, Brazil

CORE TEAM: 2016 Olympic Games- Rio, Brazil

CORE TEAM: 2016 Winter Youth Olympic Games- Lillehammer, Norway

ALL GAMES LISTED ABOVE- 2016 Olympic Games and 2016 Winter Youth Olympic Games

GENERAL INFORMATION

Name: Gender: M / F (Check one) / Gender: Male Female
Mailing Address: / City:
Province: / Postal Code:
Tel: (B) (H)
E-mail Address:
Present Employment/Employer:
Certifications: SPC Certificate Level Yes Year: SPC Diploma Level Yes Year:
Languages: First Language:Other Language(s):
Please rank the languages as follows:
0 No real ability to communicate
1Can understand basic commands and sentences
2Can fully evaluate a patient, take a history, calm an athlete in distress and explain your actions in an emergency or in a clinical setting
3Can teach, give a professional lecture and function completely with ease
ENGLISHFRENCHOTHER:
Written Competency0 1 2 30 1 2 3 0 1 2 3
Oral Competency0 1 2 30 1 2 3 0 1 2 3
Current First Responder Certification: Yes Date Obtained: (dd/mm/yy)
University Affiliation: No / Yes(Check one) / University Name:
Professional Licensing Number: / Provincial/Territorial Licensing Body:
Expiry Date:
Malpractice Insurance Policy Number:
Canadian Passport Number: / Expiry Date:

EVENT COVERAGE

INTERNATIONAL EVENT COVERAGE

Chief Therapist Experience(check all applicable Games)
Major Games:
Pan American Games Year:
Commonwealth Games Year:
Paralympic Games (Summer/Winter) Year:
Olympic Games (Summer/Winter)Year:
Developmental Games:
Francophone GamesYear:
World University Games (Summer)Year:
World University Games (Winter)Year:

SPC GAMES APPLICATION FORM

MAJOR GAMES - CORE MEDICAL TEAM Experience( check all applicable Games)
Pan American Games Year:
Commonwealth Games Year:
Paralympic Games (Summer/Winter) Year:
Olympic Games (Summer/Winter)Year:
DEVELOPMENTAL GAMES – CORE MEDICAL TEAM Experience ( check all applicable Games)
Francophone GamesYear:
World University Games (Summer)Year:
World University Games (Winter)Year:
INTERNATIONAL EVENT – HOST MEDICAL TEAM (event held in Canada) Please indicate position held in addition to the Games and Year.
Francophone GamesCT Core Medical Dedicated Team PT Year:
Pan American Games CT Core Medical Dedicated Team PT Year: World University Games CT Core Medical Dedicated Team PT Year:
Commonwealth GamesCT Core Medical Dedicated Team PT Year:
Paralympic Games CT Core Medical Dedicated Team PT Year:
Olympic Games CT Core Medical Dedicated Team PT Year:
Other Event: ______Position: ______Year:
Other Event: ______Position: ______Year:
Other Event: ______Position: ______Year:
INTERNATIONAL EVENT COVERAGE – Outside Canada Please indicate position held in addition to the Games and Year.
Francophone GamesPosition: ______Year:
Pan American Games Position: ______Year: World University Games Position: ______Year:
Commonwealth GamesPosition: ______Year:
Paralympic Games Position: ______Year:
Olympic Games Position: ______Year:
Other Event: ______Position: ______Year:
Other Event: ______Position: ______Year:
Other Event: ______Position: ______Year:
NATIONAL/PROVINCIAL/LOCAL EVENT COVERAGE
EVENT COVERAGE – NATIONAL
Canada Games (Summer or Winter)Year:
Other – For each please specify: name of event, location, year & length of coverage and position held (CT, Host Medical, Dedicated Team Therapist, other. Only 1 event per bullet line.)
EVENT COVERAGE – PROVINCIAL
For each please specify: name of event, location, year & length of coverage and position held (CT, Host Medical, Dedicated Team Therapist, other. Only 1 event per bullet line)
FULL SEASON COVERAGE – DEDICATED THERAPIST
You must be with a team for its entire season, including all travel.
Are you a Dedicated Team Therapist for a:
National Team Sport: Total years:
Provincial TeamSport: Total years:
Local TeamSport: Total years:
EVENT COVERAGE – LOCAL:
For each please specify: name of event, location, year & length of coverage and position held (CT, Host Medical, Dedicated Team Therapist, other. Only 1 event per bullet line.)
PROFESSIONAL INVOLVEMENT
INVOLVEMENT IN SPORT PHYSIOTHERAPY CANADA
Please specify any and all levels of involvement as well as length of time in each role. Scoring reflects all areas. Note that for the items listed below, the position/event must entail active involvement. Precise grading will be at the discretion of the Selection Team.
National Chair of SPC Board Dates/years of Involvement: (yyyy) to (yyyy)
National SPC Board Member Dates/years of Involvement: (yyyy) to (yyyy)
SPC Chief ExaminerDates/years of Involvement: (yyyy) to (yyyy)
SPC Credentials OfficerDates/years of Involvement: (yyyy) to (yyyy)
Provincial Executive Chairperson Dates/years of Involvement: (yyyy) to (yyyy)
Provincial Section Executive Position Dates/years of Involvement: (yyyy) to (yyyy)
SPC ExaminerYear: Year: Year: Year:
National Volunteer Team/CommitteeTime Involved: (mm/yy) to (mm/yy)
SPC Credential Program MentorTime Involved: (mm/yy) to (mm/yy)
SPC Project or Sub-CommitteesDates Involved: Committee:
(includes event/conference organizing and short term SPC projects such as Specialization)
SPC Appointed RepresentativeDates Involved: Appointed to:
(formal appointment to other national or provincial organizations as SPC representative)
Other Involvement? Please Specify:
TEACHING/PRESENTING
For which Courses/Conferences?
SPC Course Instructor
SPC Course Assistant
Ortho Course Instructor
Ortho Course Assistant
University level (Sport Med. Course Inst.)
Presentations at Conferences
Other Teaching Experience? Please provide information below:
Amount of Clinical Experience (specify number of years working in sport physiotherapy since graduation):

EDUCATION

Manual Therapy Courses(please record your highest level and year achieved):
Year Achieved
Level I – E1V1
Level II – E2V2
Level III – E3V3
Lower quadrant
Upper quadrant
Part A
Level IV
Part B
Other Manual Therapy courses, please record below:
Advanced Emergency Care/ First Aid Course (specify which course and year taken): Please note – excludes First Responder – to be recorded at start of the Application Form.
Certifications:Please record all that apply and year achieved.
Year Achieved
Acupuncture
Osteopathy
IMS/Dry Needling
ART Upper
ART Lower
Other Certifications? Please record below:
Other Sport Medicine related Courses(ie Massage Therapy, Myofasical, Muscle Energy, Strain/Counterstrain, Exercise Courses, Pelvis, Shirley Sahrman, Butler, etc. - specify name(s), year taken and length of course): Courses must be a minimum of 1 day or 7 hours to be included.
Attendance at Conferences relevant to SportPT(specify name/type, year attended – note recognition will only be given for Conferences attended within the past 5 years):

OTHER

Personal Competitive Sporting or Coaching Experience/Involvement: Please record if you have any previous or current involvement on a national team, competing at international level events. Include the sport, year(s) of involvement, position as either athlete or coach.
Managerial Experience: Share your managerial experience, be sure to record any positions you have held on Boards, committees etc. other than SPC (those should be recorded previously):

Application Submission Information

DEADLINE: 11:59pm EDT June 30th, 2015
Please E-mail your Application Form with one of the following subject lines:

“Games Application- Both Olympic Games and Youth Winter Olympics”

“Games Application- Olympic Games”

“Games Application- Youth Winter Games”

All applications must be submitted directly to Ashley Lewis by the deadline. ()