Wyatt Weisel Mental Health Grant Application

Are you filling out this form on behalf of someone else? Note: if the athlete is under the age of 18, the athlete's parent or legal guardian must complete this form. *

Is the athlete aware that you are submitting this on their behalf? *

Please provide your name, relationship to the athlete and email address so we can followup with you before the athlete. *

Please fill in the following information for the athlete.

First Name *

Last Name *

Date of Birth (mm/dd/yyyy) *

Phone Number

Email Address *

Primary location (please specify the state if in the USA or the country if primarily based outside the USA). *

Are you covered by a federal payer (e.g., Medicare or Medicaid) *

Do you have personal insurance? *

Please provide the name of your personal insurance. *

Please provide a brief description of your reason for seeking mental health support (Importantly, information provided will remain secure and confidential and will only be accessed by limited personnel within USA Cycling but outside of Sport Performance for the sole purpose of ensuring eligibility and swift resource support) *

Please indicate the type of grant your are requesting. *

Do you have a specific provider that you would like to work with? *

Thank you for submitting your grant application.