Athlete Medical Form
Required for all current and new athletes participating in Special Olympics Kentucky
Local Special Olympics Program
Athlete Information
To be completed by the athlete or parent/guardian/caregiver
Name
*
First name
Middle name
Last name
Gender
*
Female
Male
Other
Date of birth
*
-
Month
-
Day
Year
Date
Email
example@example.com
Phone number
*
Format: (000) 000-0000.
Home address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Race/Ethnicity (check all that apply)
*
American Indian/Alaskan Native
Black/African American
Middle Eastern/North African
White/Caucasian
Asian American
Hispanic/Latino
Native Hawaiian/Pacific Islander
Unknown
Other
Language spoken by athlete
*
English
Spanish
American Sign Language
Other
Check if any of the following apply
*
Nonverbal
Legally blind
Deaf
None
Parent/Guardian Information
Required if a minor or otherwise has a legal guardian
Parent name
First Name
Last Name
Relationship to athlete
Email
example@example.com
Phone number
Format: (000) 000-0000.
Home address (type 'same' if same as athlete)
Emergency Contact
Name
*
First name
Last name
Phone number
*
Format: (000) 000-0000.
Relationship to athlete
*
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Associated Conditions
MANDATORY: This section must be completed, or the medical form is NOT valid
Check all that apply
*
Autism
Cerebral Palsy
Down Syndrome
Fetal Alcohol Syndrome
Marfan Syndrome
Spina Bifida
Epilepsy
Fragile X Syndrome
Other
Assistive Devices and Accommodations
Do you use any of the following?
Mobility Devices
*
Walker
Braces or crutches
Wheelchair
Removable orthotics
Prosthetics
None
Lifestyle Aids
*
CPAP
Dentures
Glasses, contacts, or protective eyewear
None
Communications
*
Hearing aid
Communication device
Sign language
None
Medical Devices
*
Implantable cardioverter defibrillator (ICD)
Implantable device for seizure management
VP shunt
Pacemaker
None
Do you have any dietary requirements?
*
Yes
No
If yes, please specify
Do you use other assistive devices?
*
Yes
No
If yes, please specify
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General Health Questions
Please answer the following to the best of your knowledge
Do you have a heart condition?
*
Yes
No
Do you have asthma?
*
Yes
No
Do you have diabetes that requires you to take insulin?
*
Yes
No
Do you have a vision impairment?
*
Yes
No
Do you have a hearing impairment?
*
Yes
No
Do you have a bleeding disorder?
*
Yes
No
Has a doctor ever limited your participation in sports?
*
Yes
No
Do you have epilepsy or another type of seizure disorder?
*
Yes
No
Do you have sickle cell disease?
*
Yes
No
Have you ever had a concussion?
*
Yes
No
If yes, please add the date of last concussion
-
Month
-
Day
Year
Date
Do you have any behavioral, mental health, and/or sensory conditions?
*
Yes
No
If yes, please specify
Do you have any allergies that require an EpiPen?
*
Yes
No
If yes, please list them
Medication and Treatment
Please list any medications and their dosages that you are currently taking (if applicable)
Medication list
Name of person completing form
*
First Name
Last Name
Today's date
*
-
Month
-
Day
Year
Date
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Waivers, Releases, and Policies
Please take time to read our release waiver before signing
Do you have a religious or other objection to receiving medical treatment?
*
Yes
No
Do you object to receiving blood transfusions if necessary?
*
Yes
No
Athlete signature (if applicable)
Parent/Guardian signature
Date signed
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: