UNITED STATES SPORTS CHIROPRACTIC FEDERATION
USSCF EVENT CREDENTIALING APPLICATION

Please Note: The ICSSD (International Chiropractic Sports Science Diploma) is mandatory to participate as a treating DC at all USSCF and FICS events.
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The following application is to be used by the USSCF for the selection process for events of the federation. All information is confidential. It is understood that this application is for information only and does not in any way guarantee the applicant a position at a certain event. It is also understood that this information is a guide for the Federation for its selection process but may not be limited to its outcomes. The intent of the USSCF is to select the most qualified and available personal for their contingency but realizes that certain constraints will be imposed by some events and certain criteria will have to be met for some events. For International competitions, it is logical that an International contingency should be selected if possible.

Section 1 - Personal Data

Name:

Address:

State: Zip Code: Country:

Phone: Fax:

Email:

 

Section 2 - Postgraduate Credentials

DACBSP

FCCSS (C)

CCSS (C)

Masters Of Sports Science

CCSP

ICSSD

MD, DO, PHD, other chiropractic diplomat

PT

EMT, ATC, PERSONAL TRAINER,CMT

Other sports specific certifications or degrees:

 

Section 3 - Experience

Team doctor at athletic events: please list the name and the location of each event you have served as a team doctor:

International credential with polyclinic, national team or federation:

National:

Regional:

 

Section 4 - Experience

Served as team chiropractor for an organized team for three years. (Minimum of high school involvement). Please list the team and primary contact person:

 

Section 5 -Experience

Served as a sports chiropractor at an athletic training center:

USOTC

other training sites please list:

 

Section 6 - Experience

List total years in active practice: years

 

Section 7 - Offices held in a sports chiropractic organization:

International sports chiropractic organization - Organization and position held:

National sports chiropractic organization - Organization and position held:

Regional or state sports chiropractic organization - Organization and position held:

 

Section 8 - Attendance at a sports symposium

International Sports Symposium - Name, date and location of symposium:

National Sports Symposium - Name, date and location of symposium:

 

Section 9 - Personal experience at college level or higher as an athlete: list the sport and team:

 

Section 10 - Evidence of scholarly productivity in literature relating directly to sports.

Author of book: list title and publisher:

Chapter in a book: list title and publisher:

Title of article and name of journal published:

 

Section 11 - Fluent in a foreign language: list

 

Section 12 - Active member in sports organization:

International and national sports council:

State sports chiropractic organization:

Other sports organization:

 

Section 13 - Number in the order of most experience the following sports you have directly been involved as a sports chiropractor:

athletics
basketball
boxing
cycling
soccer
handball
weightlifting
judo
wrestling
swimming
table tennis
taekwondo
rowing
badminton
baseball
canoeing
equestrian
fencing
gymnastics
field hockey
yachting
pentathlon
softball
tennis
shooting
archery
volleyball
other

Section 14 - Number in the order of the most interest the following events you would like to participate but you have no experience:

athletics
basketball
boxing
cycling
soccer
handball
weightlifting
judo
wrestling
swimming
table tennis
taekwondo
rowing
badminton
baseball
canoeing
equestrian
fencing
gymnastics
field hockey
yachting
pentathlon
softball
tennis
shooting
archery
volleyball

 

Full Name: Email:

I certify that I have read, agree to and understand the USSCF Manual (type the word "yes" in the box) - View it here.

I certify that the above stated information is accurate and verifiable (type the word "yes" in the box).

Should you have any questions, please call Monty Wilburn, Secretary General, USSCF at 970-224-2282.