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Athlete Registration Renewal Form
Required annually for all athletes participating in Special Olympics (to be completed by athlete or parent/guardian/caregiver)
Athlete Name
*
First Name
Last Name
Athlete Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
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12
13
14
15
16
17
18
19
20
21
22
23
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25
26
27
28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
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1948
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Local Special Olympics Program
*
Phone Number
Format: (000) 000-0000.
E-mail
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Female
Male
Other
Have there been any changes to your health in the past year? *If Yes, please complete health history section. *If no, you can skip the health history section and go straight to the signature section at the bottom.
yes
no
Parent/Guardian Information
Required if minor or otherwise has a legal guardian
Name
First Name
Last Name
Relationship to Athlete
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact
If different than Parent/Guardian Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to athlete
Health History
List any allergies and/or dietary requirments:
Health History: Health and/or mobility aids the athlete possesses and may use during Special Olympic participation
CPAP
Prosthetics
Dentures
Eyeglasses/Contacts/Protective Eyewear
Hearing Aid/Communication Device
Pacemaker/Implanted Defibrillator
Implantable Device for Seizure
Wheelchair/Walker/Leg Braces
VP Shunt
None
Other
General Health Questions:
Do you have any of the following?
Heart Condition?
Asthma?
Diabetes?
Vision Impairment?
Hearing Impairment?
Bleeding Disorder?
Sickle Cell Disease?
Epilepsy or any type of seizure disorder?
Have you ever had a head injury or concussion?
Yes
No
If yes, please note the number of head injuries/concussions along with the date of most recent:
If yes to any of the above general health questions, please provide additional details:
Medication and Treatment
Have there been any changes to your prescriptions, over-the-counter medications or treatments?
Yes
No
If yes, please list below: Medication, Dosage and Times per day
Do you have severe allergies that requires the use of an EpiPen?
Yes
No
If yes- please specify if it is to any of the following:
Insect Stings
Medication/drugs
Food
Latex
Other
Who is completing this form?
*
Athlete
Parent/Gaurdian
Caregiver/Other Family Member
Healthcare Provider
Other
I certify the information on the form is true and correct to the best of my knowledge.
*
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