Special Olympics Kansas Class A Coach/Unified Partner Registration

Special Olympics Kansas Athlete Registration
Dear Parent, Athlete or Friend:

Welcome to Special Olympics Kansas! Thank you for taking time to enroll someone you care about in Special Olympics. Special Olympics is a year-round program of sports training, education, and competition for persons with intellectual disabilities, age eight years and older. The goal of the program is to provide continuing opportunities for the athletes to develop physical fitness, demonstrate courage, experience joy and participate in the sharing of skills and friendship with their families, other athletes and the community.

Steps to Becoming a registered Special Olympics Kansas athlete:

1. Complete this Athlete Registration Form. A parent/guardian or adult athlete must sign the release statement.

2. Complete the Special Olympics Kansas Medical Form. Arrange for a physical examination and your athlete’s medical history to be completed. This can be completed by your regular Physician, a Medical Doctor, Doctor of Osteopathy, Doctor of Chiropractic, Physician’s Assistant or Advanced Registered Nurse Practitioner (ARNP). Some Physicians will perform the necessary examination for free or at reduced cost when asked to do so for Special Olympics. Special Olympics Kansas does accept school physicals or similar physical exam/medical releases that clearly state the athlete is cleared to participate in physical activity and is signed by a medical professional.

General Statement of Eligibility. Special Olympics training and competition is open to every person with intellectual disabilities who is at least eight years of age and who registers to participate in Special Olympics.

Once the enrollment forms are completed and received by SOKS the registered athlete is eligible to compete at the local, regional and state events. SOKS will provide the athlete's local program with registration and medical paperwork for their files.

If you need assistance in finding a local program, please contact Chris Burt at burtc@soks.org or at 913-600-2240.
Local Special Olympics Program
Are you new to Special Olympics Kansas or re-registering?*

NewRe-Registering
Athlete Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender*

MaleFemaleOther Gender IdentityNo Answer
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Race/Ethnicity (Optional):

American Indian/Alaskan NativeAsianBlack or African AmericanHispanic or LatinxMiddle Eastern/North AfricanNative Hawaiian or Other Pacific IslanderWhite or CaucasianTwo or More RacesUnknownPrefer not to answer
Language(s) Spoken by Athlete (Optional):

EnglishSpanishOther
Parent/Guardian Information

Required if minor or otherwise has a legal guardian
Name

First NameLast Name
Relationship to Athlete
Address

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Emergency Contact

If different than Parent/Guardian Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to athlete
Associated Conditions
Check all that apply:

AutismCerebral PalsyDown SyndromeFetal Alcohol SyndromeMarfan SyndromeSpina BifidaEpilepsyFragile X SyndromeOtherUnknown
Please specify other known intellectual disability diagnoses:
Assistive Devices and Accommodations

Do you use any of the following? Check all that apply:
Mobility*

WalkerBraces or crutchesWheelchairRemovable orthoticsProstheticsNone
Lifestyle Aids*

CPAPDenturesGlasses, contact lenses, or protective eyewearNone
Communications*

Hearing AidCommunication devicesSign LanguageNone
Medical Devices*

Implantable cardioverter defibrillator (ICD)Implantable device for seizure managementVP ShuntPacemakerNone
Do you have a specific dietary requirement?
Do you use other assistive devices?
General Health Questions
Do you have a heart condition?*

YesNo
Do you have asthma?*

YesNo
Do you have diabetes that requires you to take insulin?*

YesNo
Do you have a vision impairment?*

YesNo
Do you have a hearing impairment?*

YesNo
Do you have a bleeding disorder?*

YesNo
Has a doctor ever limited your participation in sports?*

YesNo
Do you have epilepsy or any type of seizure disorder?*

YesNo
Do you have sickle cell disease?*

YesNo
Have you ever had a concussion?*

YesNo
If yes, please specify how many in your lifetime:
Date of last one:

MonthDayYear
Date
Do you have behavioral, mental health, and/or sensory conditions?*

YesNo
If yes, please specify:
Do you have severe allergies that requires the use of an EpiPen?*

YesNo
If yes, please specify if it is to any of the following:

Insect stingsFoodMedication/DrugsLatexOther
Please specify if other:
Medication and Treatment
Are you taking any prescription or over-the-counter medications or treatments? (Including birth control pills, insulin, multivitamins, allergy shots or pills, EpiPen, asthma inhalers, epilepsy medication, anti-inflammatory medication, supplements of any kinds, etc)*

YesNo

Type a question

	Medication, Vitamin or Supplement Name	Dosage	Times per day
1
2
3
4
5
6
7
8
9
10

Name of person completing the form:*

First NameLast Name
Today's Date*

MonthDayYear
Date
Is this form being completed by someone other than the athlete?*

YesNo
If yes, please select the relationship to athlete:

Parent/guardianCaregiverFamily memberHealthcare providerCoachOther
Waivers, Releases, And Policies

Please read the following information and check boxes fully before signing.
I agree to the following:

1. Ability to Participate. I am physically able to take part in Special Olympics activities, and will abide by all applicable rules, requirements and codes of conduct.

2. Likeness Release. I give permission to Special Olympics, Inc., Special Olympics games organizing committees, Special Olympics accredited Programs (collectively “Special Olympics”), as well as official Special Olympics supporters and partners that have authorization from Special Olympics, to use my likeness, photo, video, name, voice, words, biographical information and similar or related material (my “likeness”) to promote Special Olympics and raise funds for Special Olympics. I understand that my likeness may be used in all forms of media in local or global campaigns – including those by supporters and partners of Special Olympics – but understand that my likeness will not be used to endorse commercial products or services. I understand that I will not be compensated for the use of my likeness.

3. Overnight Stay. For some events, overnight accommodations may be required. If I have questions, I will contact my Special Olympics Program.

4. 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 have the right to decline Health programming treatment (which is different from sideline or emergency medical care) at any time.”

5. 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:

- using 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.

- using my contact information for communicating with me about Special Olympics.

- sharing my personal information confidentially with (i) researchers such as universities and public health agencies 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 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.

Privacy Policy. Personal information may be used and shared consistent with this form and as further explained in the Special Olympics privacy policy at www.SpecialOlympics.org/Privacy-Policy.
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. If either box is marked, an EMERGENCY MEDICAL CARE REFUSAL FORM must be completed.

I have a religious or other objection to receiving medical treatment (Not common.)I do not consent to blood transfusions. (Not common.)
SYMPTOMS FOR SPINAL CORD COMPRESSION and ATLANTOAXIAL INSTABILITY

(For athlete with Down syndrome only)
If I (or the athlete) have been diagnosed with or experienced any of the following symptoms that have increased in severity over the past three years – difficulty controlling bowels or bladder; numbness or tingling in legs, arms, hands, or feet; weakness in arms, legs, hands or feet; burner/stinger/pinches nerve, pain in neck, back shoulders, arms, hands, buttocks, legs or feet; spasticity or paralysis – I must obtain a review and permission from a licensed medical practitioner to train and/or participate in Special Olympics activities.
WAIVER AND RELEASE OF LIABILITY / ASSUMPTION OF RISK / INDEMNIFICATION

In consideration of being allowed to participate in any way in Special Olympics activities, the undersigned acknowledges, appreciates,and agrees that:
1. While particular rules and personal discipline may reduce this risk, the risk of illness (including communicable diseases), injury (including concussion), disability, and death does exist;

2. If I observe any unusual or significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest Special Olympics representative immediately; and,

3. I understand the risks involved with participation in Special Olympics activities. I fully accept and assume all risks and all responsibility for losses, costs, and damages I may incur as a result of my participation. To the fullest extent of the law, I release and agree not to sue any Special Olympics organization, its directors, agents, volunteers, and employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable owners and lessors of premises on which any Special Olympics activity is occurring (“Releasees”) related to any liabilities, claims, or losses on my account caused or alleged to be caused in whole or in part by the Releasees even if arising from the negligence of the Releasees. I have read this release of liability and assumption of risk provision, fully understand its terms, acknowledge that I have given up substantial rights by signing it, and sign it freely and voluntarily without any inducement. I further agree that if, despite this release, I, or anyone on my behalf, makes a claim against any of the Releasees, I will indemnify and hold harmless each of the Releasees from any such liabilities, claims, or losses as the result of such claim. I agree that if any part of this form is held to be invalid, the other parts shall continue in full force and effect.
Signature
Athlete Name

First NameLast Name
I have read and understand this form. If I have questions, I will ask. By signing, I agree to this form.
Athlete Signature (required for adult athlete with capacity to sign legal documents)

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Date

MonthDayYear
Date
Parent Guardian Name

First NameLast Name
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 (required for athlete who is a minor or lacks capacity to sign legal documents)

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Date

MonthDayYear
Date
EVALUATION AND RESEARCH (OPTIONAL)
Special Olympics wants to help our athletes and their families stay healthy and happy. We may take part in research studies and would
share information for your potential participation. All studies will be checked by the Special Olympics Chief Health Officer.
Would you or your family be interested in learning about research studies?

YesNo
Upon submitting the form, your application will be submitted to a Special Olympics Kansas staff member.
Should be Empty:

Special Olympics Kansas Athlete Registration

Parent/Guardian Information

Emergency Contact

Associated Conditions

Assistive Devices and Accommodations

General Health Questions

Medication and Treatment

Waivers, Releases, And Policies

SYMPTOMS FOR SPINAL CORD COMPRESSION and ATLANTOAXIAL INSTABILITY

WAIVER AND RELEASE OF LIABILITY / ASSUMPTION OF RISK / INDEMNIFICATION

Signature

EVALUATION AND RESEARCH (OPTIONAL)