ATHLETE REGISTRATION FORM

ATHLETE REGISTRATION FORM
County/Local Program:
Are you a new athlete to Special Olympics or Re-Registering?

New Re-Registering
ATHLETE INFORMATION
Name

First Name Last Name
Preferred Name:
Date of Birth

Month Day Year
Date
Race/Ethnicity (Optional):

American Indian/Alaskan Native Black or African American White Asian Native Hawaiian or Other Pacific Islander Two or More Races Hispanic or Latino (specific origin group)
Languages Spoken in Athlete's Home (optional)

English Spanish Other (please list)
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Sports/Activities
Athlete Employer, if any (optional)
Does the athlete have the capacity to consent to medical treatment on his or her own behalf?

Yes No
Parent / Guardian Information (required if athlete is a minor or otherwise has a legal guardian)
Parent/Guardian Name

First Name Last Name
Relationship
Same Contact Info as Athlete

Yes
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact Information
Same as parent/guardian

Yes
Name

First Name Last Name
Phone Number
Please enter a valid phone number.
Relationship
Physician & Insurance Information
Primary Care Physician Name
Phone Number
Please enter a valid phone number.
Insurance Company
Insurance Policy Number
Insurance Group Number
Athlete Medical Form HEALTH HISTORY

(To be completed by the athlete or parent/guardian/caregiver and brought to exam)
Athlete First & Last Name:

First Last
Preferred Name:
Athlete Date of Birth (mm/dd/yyyy):

Month Day Year
Date
Gender:

Female Male Other
STATE PROGRAM:
E-mail:
example@example.com
ASSOCIATED CONDITIONS - Does the athlete have (check any that apply):

Autism Down Syndrome Fragile X Syndrome Cerebral Palsy Fetal Alcohol Syndrome Other syndrome, please specify
Allergies & Dietary Restrictions

No Known Allergies Latex Medications Insect Bites or Stings Food
Please list Medication allergies:
Please list Insect Bite or Sting allergies:
Please list Food allergies:
List any special dietary needs:
ASSISTIVE DEVICES - Does the athlete use (check any that apply):

Brace C-PAP Machine Glasses or Contacts Implanted Device Removable Prosthetics Colostomy Crutches or Walker G-Tube or J-Tube Inhaler Splint Communication Device Dentures Hearing Aid Pacemaker Wheel Chair
SPORTS PARTICIPATION
List all Special Olympics sports the athlete wishes to play:
Has a doctor ever limited the athlete's participation in sports?

No Yes (please describe)
SURGERIES, INFECTIONS, VACCINES
List all past surgeries:
Does the athlete currently have any chronic or acute infection?

No Yes (please describe)
Has the athlete ever had an abnormal Electrocardiogram (EKG) or Echocardiogram (Echo)?

No Yes (please describe)
Has the athlete had a Tetanus vaccine in the past 7 years?

No Yes
EPILEPSY AND/OR SEIZURE HISTORY
Epilepsy or any type of seizure disorder

No Yes (please describe)
If yes, had seizure during the past year?

No Yes
MENTAL HEALTH
Self-injurious behavior during the past year

Aggressive behavior during the past year
Self-injurious behavior during the past year

No Yes
Aggressive behavior during the past year

No Yes
Depression (diagnosed)

No Yes
Anxiety (diagnosed)

No Yes
Describe any additional mental health concerns:
FAMILY HISTORY
Has any relative died of a heart problem before age 50?

No Yes
Has any family member or relative died while exercising?

No Yes
List all medical conditions that run in the athlete’s family:
Athlete Medical Form HEALTH HISTORY
Athlete’s First and Last Name:

First Name Last Name

Type a question

Yes

Loss of Consciousness

High Blood Pressure

Stroke/TIA

Dizziness during or after exercise

High Cholesterol

Concussions

Headache during or after exercise

Vision Impairment

Asthma

Chest pain during or after exercise

Hearing Impairment

Diabetes

Shortness of breath during or after exercise

Enlarged Spleen

Hepatitis

Irregular, racing or skipped heart beats

Single Kidney

Urinary Discomfort

Congenital Heart Defect

Osteoporosis

Spina Bifida

Heart Attack

Osteopenia

Arthritis

Cardiomyopathy

Sickle Cell Disease

Heat Illness

Heart Valve Disease

Sickle Cell Trait

Broken Bones

Heart Murmur

Easy Bleeding

Dislocated Joints

Endocarditis

If female athlete, list date of last menstrual period:

Month Day Year
Date
Describe any past broken bones or dislocated joints (if yes is checked for either of those fields above):
List any other ongoing or past medical conditions:

Neurological Symptoms for Spinal Cord Compression and Atlanto-axial Instability

Yes

No, this is not new or worse in the past 3 years

Yes, this is new or worse in the past 3 years

Difficulty controlling bowels or bladder

Numbness or tingling in legs, arms, hands, or feet

Weakness in legs, arms, hands, or feet

Burner, stinger, pinched nerve or pain in the neck, back, shoulders, arms, hands, buttocks, legs or feet

Head Tilt

Spasticity

Paralysis

If yes, is this new or worse in the past 3 years?
PLEASE LIST ANY MEDICATION, VITAMINS OR DIETARY SUPPLEMENTS BELOW

(includes inhalers, birth control or hormone therapy)

Medication, Vitamin or Supplement Name

Dosage

Times per Day

Medication, Vitamin or Supplement Name

Dosage

Times per Day

Medication, Vitamin or Supplement Name

Dosage

Times per Day

Is the athlete able to administer his or her own medications?

No Yes
Name of Person Completing this Form
Relationship to Athlete
Phone
Email
example@example.com
Athlete Medical Form – PHYSICAL EXAM

(To be completed by a Licensed Medical Professional qualified to conduct exams & prescribe medications)
Athlete’s First and Last Name:
MEDICAL PHYSICAL INFORMATION
(To be completed by a Licensed Medical Professional qualified to conduct physical exams and prescribe medications)
Height
Weight
Temperature
Pulse
OSat 2
Vision
cm
kg
BMI
C
BP Right:
BP Left:
Right Vision 20/40 or better

No Yes N/A No Yes N/A
in
lbs
Body Fat
F
Left Hearing (Finger Rub)

Right Hearing (Finger Rub) No Response Can’t Evaluate Yes No Responds No Response Can’t Evaluate No Yes Clear Cerumen Foreign Body No Yes Clear Cerumen Foreign Body No RUQ RLQ LUQ LLQ Right Tympanic Membrane Clear Perforation Infection NA No Right Left Clear Perforation Infection NA Normal Diminished Hyperreflexia Good Fair Poor Normal Diminished Hyperreflexia No Yes Normal Diminished Hyperreflexia No Yes Normal Diminished Hyperreflexia No 1/6 or 2/6 3/6 or greater No Yes, describe below No 1/6 or 2/6 3/6 or greater No Yes, describe below Regular Irregular No Yes, describe below Clear Not clear Full Not full, describe below No 1 2 3 4 Full Not full, describe below No 1 2 3 4 Full Not full, describe below Yes R>L L>R Full Not full, describe below No Yes, describe Full Not full, describe below No Yes, describe No Yes, describe below
SPINAL CORD COMPRESSION & ATLANTO-AXIAL INSTABILITY (AAI) (Select one)
OR

Athlete shows NO EVIDENCEofneurological symptoms or physical findings associated with spinal cord compression or atlantoaxial instability. Athlete has neurological symptoms or physical findings that could be associated with spinal cord compression or atlanto-axial instability and must receive an additional neurological evaluation to rule out additional risk of spinal cord injury prior to clearance for sports participation.
ATHLETE CLEARANCE TOPARTICIPATE(TO BE COMPLETED BY EXAMINER ONLY)
Licensed Medical Examiners: It is recommended that the examiner review items on the medical history with the athlete or their guardian, prior to performing the physical exam. If an athlete needfurther medical evaluation pleasemake a referral below and second physician for referral should complete page 4.

This athlete is ABLE to participate in Special Olympics sportswithout restrictions. This athlete is ABLE to participate in Special Olympics sports WITHrestrictions. Describe
Licensed Medical Examiners: It is recommended that the examiner review items on the medical history with the athlete or their guardian, prior to performing the physical exam. If an athlete needfurther medical evaluation pleasemake a referral below and second physician for referral should complete page 4.

This athlete MAY NOT participate in Special Olympics sports at this time & MUST be further evaluated by a physician for the following concerns:
Licensed Medical Examiners: It is recommended that the examiner review items on the medical history with the athlete or their guardian, prior to performing the physical exam. If an athlete needfurther medical evaluation pleasemake a referral below and second physician for referral should complete page 4.

Concerning Cardiac Exam cute Infection Saturation Less than 90% on Room Air Concerning Neurological Exam Stage II Hypertension or Greater Hepatomegaly or Splenomegaly Other, please describe:
This athlete is ABLE to participate in Special Olympics sports WITHrestrictions. Describe
This athlete MAY NOT participate in Special Olympics sports at this time & MUST be further evaluated by a physician for the following concerns:
Additional Licensed Examiner’s Notes and Recommended (but not required) Followup:
Additional Licensed Examiner’s Notes and Recommended (but not required) Followup:

Follow up with a cardiologist Follow up with a neurologist Follow up with a primary care physician Follow up with a vision specialist Follow up with a hearing specialist Follow up with a dentist or dental hygienist Follow up with a podiatrist Follow up with a physical therapist Follow up with a nutritionist
Additional Licensed Examiner’s Notes and Recommended (but not required) Followup:

OtherExam Notes OtherExam Notes
Name:
Name:
mail:
example@example.com
Signature of Licensed Medical Examiner

Clear
Phone:
License #:
Medical Form for US Programs – updated July 2017

Special Olympics Medical Form | 3 of 4
Athlete Medical Form – MEDICAL REFERRAL FORM
(To be completed by a Licensed Medical Professional only if referral is needed)
Athlete’s First and Last Name:
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.
Examiner’s Name:
Specialty:
I have been asked to perform an additional athlete examfor the following medical concern(s) Please describe

Concerning Cardiac Exam Acute Infection Saturation Less than 90% on Room Air Concerning Neurological Exam Stage II Hypertension or Greater Hepatomegaly or Splenomegaly Other, please describe:
In my professional opinion, this athlete MAYnow participate in Special Olympics sports indicate
restrictions or limitationsbelow

Yes Yes, but with restrictions(list below) No
Additional Examiner Notes/Restrictions:
Examiner Email:
example@example.com
Examiner Phone:
License:
Examiner’s Signature

Clear
Date

Month Day Year
Date
The athlete is a Unified Partner or a Young Athlete Participant?

This medical exam was completed at a MedFest event? Yes No This section to be completed by Special Olympics staff only, if applicable. Unified Partner Young Athlete
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:
Name

First Name Last Name
E-mail:
Email
example@example.com
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:
Signature

Clear
Date:
Date

Month Day Year
Date
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:
Signature

Clear
Date:
Date

Month Day Year
Date
Printed Name:
Type a question
Relationship:
Type a question
A1 Athlete Registration – Updated September 2017
Should be Empty:

ATHLETE REGISTRATION FORM

ATHLETE INFORMATION

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

Emergency Contact Information

Physician & Insurance Information

SPORTS PARTICIPATION

SURGERIES, INFECTIONS, VACCINES

EPILEPSY AND/OR SEIZURE HISTORY

MENTAL HEALTH

FAMILY HISTORY

PLEASE LIST ANY MEDICATION, VITAMINS OR DIETARY SUPPLEMENTS BELOW

Height

Weight

Temperature

Vision

ATHLETE CLEARANCE TOPARTICIPATE(TO BE COMPLETED BY EXAMINER ONLY)

PARTICIPANT RELEASE FORM

Athlete Name:

E-mail:

Athlete Signature:

Date:

Parent/Guardian Signature:

Date:

Printed Name:

Relationship: