Athlete Profile Form

To help in the planning and publicity efforts for the Games, we’d like to get to know more about you. You are not under any obligation to supply this information but your input will help us do a better job telling the story of the Games and organ and tissue donation. We thank you for your assistance.

 

If possible, please e-mail two recent photos of the athlete to Verena at verenah@kidney.org. Please include your name, address and phone in the body of the e-mail. If this is not possible, feel free to mail two recent photos of the athlete with the same information printed on the back of each photo. Sorry, we cannot return photots. Please mail photos to: National Kidney Foundation, Attention Verena Huetteneder, 30 East 33rd Street New York, NY 10016.

 

Full Name of Competitor:

 

Sex: male female

 

Address:

 

City:

 

State:

 

Zip:

 

Phone: (day)
              (eve)

 

E-mail:

 

Birthdate:

 

Date of transplant:

 

Organ received:

 

Type of transplant:

 

Marital status:

 

Do you have children? Yes     No
If so, please list their ages:

 

Occupation:

 

Employer:

 

Employment Status:

 

Please tell us your personal transplant story, including anything particularly unusual or dramatic that occurred:

 

Since your transplant, which of the following best describes your inclination to exercise and participate in sports and physical activity?

A. more inclined

B. less inclined

C. have not changed my level of activity

Please describe:

 

In what events are you planning to participate at the 2006 Games?

 

Have you attended other Transplant Games? If so, which ones?

 

Has anyone else in your family had a transplant?
Yes     No
If yes, please expound

 

Please describe your feelings about the Transplant Games and why you choose to participate:

 

Have any special friendships formed as a result of your participation in the Games or as a result of your transplant?
Yes     No
If yes, please explain:

 

Have there been any other events, family experiences, personal pursuits (hobbies, affiliations etc.) that have developed since your transplant which you feel the transplant experience has influenced for the good or bad? Please explain:

 

Have you had any contact with your donor family?
Yes     No
If yes, please describe

 

If you have been featured in a local or national newspaper, magazine, TV and/or radio show, please list names below (include direct web links if possible):

 

Will you allow the NKF to include your name, athlete profile information and photo:

  1. on the Transplant Games page on our web site?
    Yes     No
  2. in our “directory of athletes” and other NKF printed material?
    Yes     No

Are you interested and willing to participate in media interviews?
Yes     No

 

Digital Signature:
By clicking this box, you indicate all information submitted is correct and is provided to the NKF voluntarily.