Athlete Registration Renewal Form

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 NameLast Name
Athlete Birth Date*

MonthDayYear
Local Special Olympics Program*
Phone Number
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender

FemaleMaleOther
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.

yesno
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 / Province

Postal / 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
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

CPAPProstheticsDenturesEyeglasses/Contacts/Protective EyewearHearing Aid/Communication DevicePacemaker/Implanted DefibrillatorImplantable Device for SeizureWheelchair/Walker/Leg BracesVP ShuntNoneOther
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?

YesNo
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?

YesNo
If yes, please list below: Medication, Dosage and Times per day
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 StingsMedication/drugsFoodLatexOther
Who is completing this form?*

AthleteParent/GaurdianCaregiver/Other Family MemberHealthcare ProviderOther
I certify the information on the form is true and correct to the best of my knowledge.*

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Athlete Registration Renewal Form

Parent/Guardian Information

Emergency Contact

Health History

General Health Questions:

Medication and Treatment