• ATHLETE REGISTRATION FORM

  • ATHLETE INFORMATION

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  • Parent / Guardian Information (required if athlete is a minor or otherwise has a legal guardian)

  • Emergency Contact Information

  • Physician & Insurance Information

  • Athlete Medical Form HEALTH HISTORY

    (To be completed by the athlete or parent/guardian/caregiver and brought to exam)

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  • SPORTS PARTICIPATION

  • SURGERIES, INFECTIONS, VACCINES

  • EPILEPSY AND/OR SEIZURE HISTORY

  • MENTAL HEALTH

  • Self-injurious behavior during the past year

    Aggressive behavior during the past year

  • FAMILY HISTORY

  • Athlete Medical Form HEALTH HISTORY

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  • If yes, is this new or worse in the past 3 years?

  • PLEASE LIST ANY MEDICATION, VITAMINS OR DIETARY SUPPLEMENTS BELOW

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  • Athlete Medical Form – PHYSICAL EXAM

    (To be completed by a Licensed Medical Professional qualified to conduct exams & prescribe medications)

  • (To be completed by a Licensed Medical Professional qualified to conduct physical exams and prescribe medications)

  • Height

  • Weight

  • Temperature

  • Vision

  • SPINAL CORD COMPRESSION & ATLANTO-AXIAL INSTABILITY (AAI) (Select one)

  • ATHLETE CLEARANCE TOPARTICIPATE(TO BE COMPLETED BY EXAMINER ONLY)

  • This athlete MAY NOT participate in Special Olympics sports at this time & MUST be further evaluated by a physician for the following concerns:

  • Clear
  • Medical Form for US Programs – updated July 2017

    Special Olympics Medical Form | 3 of 4

  • Athlete Medical Form – MEDICAL REFERRAL FORM

  • This page only needs to be completed and signed if the physician on page three does not clear the athlete and indicates further evaluation is required.

    Athlete should bring the previously completed pages to the appointment with the specialist.

  • Clear
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  • Medical Form for US Programs – updated July 2017

    Special Olympics Medical Form | 4 of 4

  • PARTICIPANT RELEASE FORM

    • I agree to the following: 1.Ability to Participate. I am physically able to take part in Special Olympics activities. 2.Likeness Release. I give permission to Special Olympics, Inc., Special Olympics games organizing committees, and Special Olympics accredited Programs (collectively “Special Olympics”) to use my likeness, photo, video, name, voice, and words to promote Special Olympics and raise funds for Special Olympics. 3.Risk of Concussion and Other Injury. I know there is a risk of injury. I understand the risk of continuing to play sports with or after a concussion or other injury. I may have to get medical care if I have a suspected concussion or other injury. I also may have to wait 7 days or more and get permission from a doctor before I start playing sports again. 4.Emergency Care. If I am unable, or my guardian is unavailable, to consent or make medical decisions in an emergency, I authorize Special Olympics to seek medical care on my behalf, unless I mark one of these boxes: I have a religious or other objection to receiving medical treatment. (Not common I do not consent to blood transfusions. (Not common (If either box is marked, an EMERGENCY MEDICAL CARE REFUSAL FORM must be completed 5.Overnight Stay. For some events, I may stay in a hotel or someone’s home. If I have questions, I will ask. 6.Health Programs. If I take part in a health program, I consent to health activities, screenings, and treatment. This should not replace regular health care. I can say no to treatment or anything else at any time. 7.Personal Information. I understand that Special Olympics will be collecting my personal information as part of my participation, including my name, image, address, telephone number, health information, and other personally identifying and health related information I provide to Special Olympics (“personal information”
    • I agree and consent to Special Olympics: ousing my personal information in order to: make sure I am eligible and can participate safely; run trainings and events; share competition results (including on the Web and in news media); provide health treatment if I participate in a health program; analyze data for the purposes of improving programming and identifying and responding to the needs of Special Olympics participants; perform computer operations, quality assurance, testing, and other related activities; and provide event-related services. ousing my personal information and creating a profile of me for communications and marketing purposes, including direct digital marketing through email, SMS, social media, and other channels. osharing my personal information with (i) researchers, business partners, public health agencies, and other organizations that are studying intellectual disabilities and the impact of Special Olympics activities, (ii) medical professionals in an emergency, and (iii) government authorities for the purpose of assisting me with any visas required for international travel to Special Olympics events and for any other purpose necessary to protect public safety, respond to government requests, and report information as required by law.
    • I understand Special Olympics is a global organization with headquarters in the United States of America. I acknowledge that my personal information may be stored and processed in countries outside my country of residence, including the United States. Such countries may not have the same level of personal data protection as my country of residence, and I agree that the laws of the United States will govern your processing of my personal information as provided in this consent.
    • I have the right to ask to see my personal information or to be informed about the personal information that is processed about me. I have the right to ask to correct and delete my personal information, and to restrict the processing of my personal information if it is inconsistent with this consent.
    • Sharing of Personal Information. Personal information may be shared consistent with this form and as further explained in the Special Olympics privacy policy at www.SpecialOlympics.org/Privacy_Policy.aspx.

  • Athlete Name:

  • E-mail:

  • ATHLETE SIGNATURE (required for adult athlete with capacity to sign legal documents)

    I have read and understand this form. If I have questions, I will ask. By signing, I agree to this form.

  • Athlete Signature:

  • Clear
  • Date:

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  • PARENT/GUARDIAN SIGNATURE (required for athlete who is a minor or lacks capacity to sign legal documents)

    I am a parent or guardian of the athlete. I have read and understand this form and have explained the contents to the athlete as appropriate. By signing, I agree to this form on my own behalf and on behalf of the athlete.

  • Parent/Guardian Signature:

  • Clear
  • Date:

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  • Printed Name:

  • Relationship:

  • A1 Athlete Registration – Updated September 2017

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  • Should be Empty: