UP Combined Class A Application

Unified Partner/Class A Volunteer Registration

Release and Waiver of Liability, Assumption of Risk and Indemnity Agreement.

Stop! If you are under age 18, please fill out the combined Minor Class A/Unified Partner fillable form instead of this one. (Form can be access here: https://form.jotform.com/SpecialOlympicsMO/up-combined-minor)

Each question should be answered completely and accurately. All responses are confidential.
Staff Office Use Only
Staff Assigned Agency Name:
Role
Staff Editing
Staff Email
example@example.com
Edit Current Date/Time

MonthDayYear
Date
Registration Type*

Unified Partner
Are you a new volunteer or re-registering?*

NewRe-Registering
Your SOMO Agency/Team Name (if known)
Agency/Team Number (e.g. "33.115")
Biographical Info
First Name (Legal)*
Middle Name (Legal)
Last Name (Legal)*
Suffix (Jr., Sr., etc.)
Nickname. What name should we call you by? (Optional)
Maiden Name (if applicable)
SSN (needed for background check)*
Date of Birth*

MonthDayYear
Date
Age (calculated)
Your birthdate indicates you are under age 18. Please fill out the Minor Class A/Unified Partner form or correct your birthdate.
Gender*

MaleFemaleOther Gender Identity
Ethnicity*

American Indian/Alaskan NativeAsian AmericanBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite or CaucasianHispanic or LatinxTwo or More RacesPrefer not to answer
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Numbers (Home or Cell is required)
Cell Phone Number

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Business Phone Number (Optional)

Area CodePhone Number
E-mail*

Confirmation Email
Health Insurance Company*
Health Insurance Policy #*
In the event of an emergency, contact:
Name*
Relationship to you*
Emergency Contact Phone*

Area CodePhone Number
Health History
1. Heart Disease/heart defect/high blood pressure*

YESNO
2. Chest pain*

YESNO
3. Seizures/epilepsy/ fainting spells*

YESNO
4. Diabetes*

YESNO
5. Concussion or serious head injury*

YESNO
6. Major surgery or serious illness*

YESNO
7. Heat stroke/exhaustion*

YESNO
8. Visual impairment/ contact lenses/glasses*

YESNO
9. Blind*

YESNO
10. Hearing impaired*

YESNO
11. Deaf/complete hearing loss*

YESNO
12. Bone or joint problems*

YESNO
13. Special Diet*

YESNO
14. Asthma*

YESNO
15. Tobacco Use*

YESNO
16. Easy Bleeding*

YESNO
17. Emotional/psychiatric/ behavioral*

YESNO
18. Sickle cell trait or disease*

YESNO
19. Immunizations up to date*

YESNO
Allergies:
Your Background
1. Do you use illegal drugs?*

YESNO
1b. If yes, specify what drug, how often you have used each drug, and the date(s) most recently used:
2. Have you ever been convicted of a criminal offense?*

YESNO
2b. If yes, provide the location, date and result/outcome for each conviction:*
3. Have you ever been charged with and/or convicted of neglect, abuse or assault?*

YESNO
3b. If yes, please explain:*
4. Has your driver’s license ever been suspended or revoked in any state?*

YESNO
4b. If yes, please provide details, including dates, reason(s), venue and disposition:*
Where do I send my application?

Select the Area office that should receive and process your form. Usually this will be based on where you live or where your SOMO Agency is located. You may also choose to submit it directly to staff in our Headquarters office in Jefferson City. If unsure, choose Headquarters. The map of Missouri below shows you which counties are generally served by our different area offices.
Select Recipient*
Please provide the name of your coach or agency head coach (if applicable):
Consent and Sign

terms/conditions, COVID and Communicable Diseases waivers
I have read and understand this form. If I have questions, I will ask. By signing, I agree to this form.*

I agreeI do not agree
Signature*
Upon submitting the form, your application will be submitted to a staff member in the office you specified above. You will also be re-directed to a third-party website so that you can submit your information for a background check, which is required of all Class A volunteers, including Unified Partners.

You will receive a copy of your submission at the email address you indicated. Email us at volunteer@somo.org if you have questions about this form or approval process.
Should be Empty:

Staff Office Use Only

Biographical Info

Your birthdate indicates you are under age 18. Please fill out the Minor Class A/Unified Partner form or correct your birthdate.

In the event of an emergency, contact:

Health History

Your Background

Where do I send my application?

Consent and Sign