Track Side Medical Staff Form
Please fill out this form if you are interested in being a medic for the WFTDA recognized tournament, K-Town Shakedown, held in Kalamazoo Michigan, on April 24-26, 2020. Our Head Medic, Dee Struction, will contact you if you are selected, and provide you with more information on scheduling. Thank you for your interest in our event!
Derby Name (if applicable)
Medical Licensure Level (please select the highest level you have achieved)
Certified First Responder
Physician w/sports medicine, orthopedic and/or ER experience
Athletic trainer w/CPR
LPN or RN w/CPR & sports medicine, orthopedic and/or ER experience
Nurse Practioner or Physician’s Assistant w/CPR & sports medicine, orthopedic and/or ER experience
CPR and Basic First Aid
CPR Expiration Date
Do you want to be placed on our league medical list or only for this single event?
Yes, please contact me for future events
No, I'm only interested in this event
Shirt Size (unisex cotton shirt)
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