Athletic Directors & Event Operators - Victory Health Solutions

Coverage Request Form

Company/School Name:

Event Contact Person:

Phone #1:

Phone #2:

Email:

Billing Address

Street Address:

City:

State:

Zip Code:

Event Address

Street Address:

Street Address 2:

City:

State:

Zip Code:

Event Date:

Arrival/Taping Time:

Event Time:

Approximate End Time:

Event Level:
YouthMiddle SchoolHigh SchoolCollegiateAdultProfessionalMulti-Level

Gender of Athletics:
MaleFemaleCo-Ed

Sport(s):

Event Type:
PracticeGameDay CampOvernight CampAT SubstituteClinicOther

Number of Athletes:

Number of facilities or fields to be covered:

Is there an Automated External Defibrillator (AED) at your facility?
YesNo

If yes, where is the AED located?

Does the Athletic Trainer need to bring their own supplies?
YesNo

Does the Athletic Trainer need to bring injury ice?
YesNo

Completed Company/Business W9 (Maximum File Size: 3MB)

Emergency Action Plan (EAP) (Maximum File Size: 3MB)

Athletic Schedules (Maximum File Size: 3MB)

Special Instructions:

How did you hear about us?

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