NATA SSATC / Gatorade Secondary School Athletic Trainer Recognition Award Nomination Application

Name of Nominee: *

Home Street Address 1: *

Home Street Address 2:

Home Address City: *

Home Address State: *

Home Address Zip: *

Home Phone:

e-mail Address: *

School Street Address 1: *

School Street Address 2:

School Address City: *

School Address State: *

School Address Zip: *

School Phone:

Cell:

NATA District: *

Athletic Training Experience

Current high school employed: *

Years employed at current high school: *

Previous high schools employed & years employed at each:

Teaching of ATSA’s

Years of Sports Medicine Course:

Years of First Aid and CPR:

Years of Athletic Training Course:

ATSA’s who are now Medical Professionals

ATCs, PT, OT, Nurse, Physician, etc

Number: *

Additional Experience:

Prom chaperone, Powder Puff Game coverage, Senior Trip chaperone, Staff development instructor (CPR, etc..), develop conditioning programs for teams/students, etc…

List events:

List the outstanding accomplishments of the candidate’s athletic training career. If additional space is needed, please submit additional papers.

Outstanding Accomplishments:

Name of Nominating Representative : *