YOUNG ATHLETES REGISTRATION

YOUNG ATHLETES REGISTRATION
YOUNG ATHLETES PARTICIPANT INFORMATION
Young Athlete Name*
Date of Birth*

MonthDay Year
Date
Gender*

MaleFemale
Has an Intellectual or Developmental Disability?*

YesNo
T-Shirt Size*

Youth SmallYouth MediumYouth Large
Please mark items you would like Special Olympics to know about:

Requires Wheelchair Accessible LocationsLanguage NeedsMedical ConditionsSpecial DietOther
Language Needs:
Medical Conditions:
Special Diet:
Other:
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name*
Relationship*
Street Address*
City*
State/Province*
Postal Code*
Email*
example@example.com
Phone*
EMERGENCY CONTACT INFORMATION (other than Parent/Guardian; Parent/Guardian will be contact first in an emergency)
Contact Name*
Relationship*
Phone*
SPECIAL OLYMPICS PROGRAM INFORMATION
Local Program Name
YOUNG ATHLETES RELEASE FORM
I am the Parent or Guardian of the Young Athletes participant named below and agree to the following:

1. Able to Participate. The Young Athlete is able to take part in Special Olympics. I understand there is a risk of injury.

2. Photo Release. Special Olympics organizations may use the Young Athlete’s picture, video, name, voice, and words to promote Special Olympics.
3. Emergency Care. If a medical emergency should arise during the Young Athlete’s participation in Special Olympics activities at a time when a parent or guardian is not present to make medical decisions, I consent to medical care for the Young Athlete if needed, unless I check one of these boxes:

I have a religious or other objection to the Young Athlete receiving medical treatment.I consent to emergency medical care, but I do not consent to blood transfusions for the Young Athlete. (If either box is checked, an EMERGENCY MEDICAL CARE REFUSAL FORM must be completed.)
4. Health Programs. If the Young Athlete takes part in a Special Olympics health program, I consent to health activities, exams, and treatment for the Young Athlete. This should not replace regular health care. I can say no to treatment or anything else any time for the Young Athlete.

5. Personal Information. I understand personal information may be used and shared by Special Olympics to:
- Make sure the Young Athlete can participate safely;
- Run trainings and events and share results;
- Put the Young Athlete’s information in a computer system;
- Provide health treatment, make referrals, consult doctors, and remind me about follow-up services;
- Research, share, and respond to needs of Special Olympics participants (identifying information removed if shared publically); and
- Protect health and safety, respond to government requests, and report information required by law. I can ask to see and change the Young Athlete’s information. I can ask to limit how the information is used.
6. Concussions. I understand the risk of concussions and continuing to play sports with a concussion. The Young Athlete may have to get medical care if a concussion is suspected. The Young Athlete also may have to wait 7 days or more and get permission from a doctor before they start playing sports again.
YOUNG ATHLETE NAME:*
PARENT/GUARDIAN SIGNATURE
I am a parent or guardian of the Young Athlete. I have read and understand this form. By signing, I agree to this form on my own behalf and on behalf of the Young Athlete.
Signature*

Clear
Date:*

MonthDay Year
Date
Printed Name:*
Relationship:*
Should be Empty:

YOUNG ATHLETES REGISTRATION

YOUNG ATHLETES PARTICIPANT INFORMATION

PARENT/GUARDIAN INFORMATION

SPECIAL OLYMPICS PROGRAM INFORMATION

YOUNG ATHLETES RELEASE FORM

PARENT/GUARDIAN SIGNATURE