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.

Organization Information

Question Title

* 1. Organization Information

Type of Organization

Question Title

* 2. Type of Organization

Applicant Information

Question Title

* 3. Applicant Information

State(s) Where Coverage Will Occur

Question Title

* 4. State(s) Where Coverage Will Occur

Type of Event

Question Title

* 5. Type of Event

Participant Demographics

Question Title

* 6. Participant Demographics

Type of Service / Coverage

Question Title

* 7. Type of Service / Coverage

Event Details

Question Title

* 8. Event Details

Start Date/Time
End Date/Time
Number of Games to be Covered

Question Title

* 9. Number of Games to be Covered

Number of Athletic Trainers Requested

Question Title

* 10. Number of Athletic Trainers Requested

Venue Information

Question Title

* 11. Venue Information

On-Site Contact Information - Day of Event

Question Title

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

On-Site Supplies Available

Question Title

* 13. On-Site Supplies Available

How Did You Hear About our Athletic Training Services?

Question Title

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

Other Pertinent Details Regarding Event

Question Title

* 15. Other Pertinent Details Regarding Event

T