• SOVT Athlete/Unified Partner Registration Form

  • Registering as an:*
  • Gender:*
  • Date of birth (dd/mm/yyyy)*
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  • Athlete Phone type
  • Athlete/Partner Race/Ethnicity*
  • Language(s) Used by Athlete/Partner

  • Parent/Guardian Information - Required if minor or otherwise has a legal guardian.

  • Does athlete/partner have a legal guardian?*
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  • Parent/Guardian Phone type:

  • Emergency Contact Information - Required for all participants

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  • Emergency Contact Phone type*
  • Emergency Contact Relationship to Athlete/Partner*

  • Participant Information - Mandatory for athletes

  • Associated Intellectual/Developmental Disability Conditions or Diagnoses
  • Assistive Devices and Accommodations (Mobility)
  • Assistive Devices and Accommodations (Lifestyle Aids)
  • Assistive Devices and Accommodations (Communications)
  • Assistive Devices and Accommodations (Medical Devices)
  • Do you have any specific dietary requirements
  • Do you use other assistive devices

  • General Health Questions

  • Do you have a heart condition?
  • Do you have severe asthma requiring the use of an inhaler?
  • Do you have diabetes that requires you to take insulin?
  • Do you have a vision impairment?
  • Do you have a hearing impairment?
  • Do you have a bleeding disorder?
  • Do you have epilepsy or any type of seizure disorder?
  • Do you have sickle cell disease?
  • Has a doctor ever limited your participation in sports?
  • Have you ever had a concussion?

  • A physician or licensed provider physical examination is required prior to participation unless you can provide proof of past medical clearance related to recommendations to limit participation in sports.

  • Are you able to provide proof of past medical clearance?
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  • Date of last concussion (mm/yyyy)
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  • A Physical Examination is Required Prior to Participation

  • Athletes who respond "yes" for a concussion occuring within 31 days prior to form completion and/or a response indicating a doctor's recommendation to limit participation are prohibited from particpation until proof of medical clearance can be provided.

    Action: A physician or person licensed to undertake a physical examination must confirm the suitability of the athlete to participate in Special Olympics sports by completing a medical form.

    Download the form here: https://media.specialolympics.org/resources/leading-a-program/registration-forms/Athlete-Medical-Form-Aug-22-2024.pdf 

    Once completed, you may scan and email the form to paperwork@vtso.org 
    OR 
    upload the form at the following link: https://form.jotform.com/252585779443068 

  • Do you have behavioral, mental health, and/or sensory conditions?
  • Do you have severe allergies that require the use of an EpiPen?
  • If yes, please identify allergies

  • Medication and Treatment - Please list:

  • 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 kind, etc.)
  • Please list medications:
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  • Athlete Info/Support Plan

    Required for participants with certain health conditions, optional/encouraged for all!

  • This plan will help coaches, teachers, volunteers, etc. to understand and support an athlete's specific needs, covering medical, behavioral, communication, and sensory needs.

    Use the headings in the grey boxes of the form linked below to complete pertinent information to ensure health, safety, and a positive training experience.

     

     Access the full Athlete Info/Action Plan template here: https://form.jotform.com/260193947841061 

    If this plan is required for your registration, applicable fields will appear below.

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  • Complete the following information about severe asthma, as applicable
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  • Complete the following information about seizures, as applicable
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  • Complete the following information about severe allergy/allergies, as applicable:
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  • Complete the following information about heart/cardiac condition, as applicable
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  • Complete the following information about diabetes requiring the use of insulin, as applicable
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  • Complete the following information about bleeding disorder, as applicable
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  • Complete the following information about sickle cell disease, as applicable
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  • Is this form being completed by someone other than the athlete/partner?
  • If yes, please select the relationship to athlete/partner:
  • Today's date (mm/dd/yyyy)
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  • Renewal date (mm/dd/yyyy)
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    2 digit month, 2 digit day, 4 digit year

  • WAIVERS, RELEASES, AND POLICIES

  • Please read the following information and review check boxes fully before signing.

    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. 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:

  • These are uncommon. (If a box is marked, an EMERGENCY MEDICAL CARE REFUSAL FORM must be completed)

  • Emergency Medical Care Refusal - Additional form

    Required for participants with religious or other objections to receiving medical care, including blood transfusions

  • Instructions: Only complete this Emergency Medical Refusal Form (this “Form”) if you do not consent to emergency medical care on religious or other grounds and have marked a box under the Emergency Care provision on the Special Olympics Athlete Registration Form (“Athlete Registration Form”).

    I am a Special Olympics Athlete with the capacity to sign legal documents on my own behalf and agree to the following; or I am the Parent/Guardian of the Athlete named below who is a minor or lacks the capacity to sign legal documents and agree to the following on their behalf.


    1. No Consent to Emergency Medical Care. I understand that the Athlete Registration form requires Athletes or their Parents/Guardians to consent to emergency medical care for an Athlete if needed in an emergency. Based on my religious beliefs and/or other reasons I DO NOT CONSENT to emergency medical care in an emergency.

  • Please re-confirm your objections to receiving Emergency Medical Care.

  • 2. Assumption of Risk; Waiver and Release of Liability; Indemnification. I understand the risks involved with
    participating in Special Olympics activities and fully accept and assume all risks and all responsibility for
    losses, costs, and damages I may incur as a result of my participation. By marking one or more of the boxes
    and adding my initials in Section 1 above, to the fullest extent of the law, I release and agree not to sue SOI,
    any Special Olympics Program (a “Program” or “Programs”), Local Organizing Committee or other Special
    Olympics organization, or their directors, agents, volunteers, and employees, other participants, sponsoring
    agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises (collectively, the
    “Releasees”) for any claims that may arise out of taking or failing to take measures to provide me with
    emergency medical care even if arising from the negligence of the Releasees. I am agreeing to this release,
    and acknowledge I have given up substantial rights, because I have refused, knowingly and voluntarily,
    without inducement, to give the Releasees permission to take emergency measures, and I am expressly
    withholding consent to emergency medical care on religious or other grounds. 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 resulting from that claim. I agree
    that if any part of this Form is held to be invalid, the remaining parts shall continue in full force and effect.

  • I agree

  • 3. Printed Instructions. I agree to carry printed instructions that describe my religious or other objections to
    emergency medical care as described in this Form and how I wish the person accompanying me to respond
    if I get sick or hurt and cannot speak for myself. I agree to carry these printed instructions with me at all
    times during my participation in any Special Olympics activity, including during mealtimes, in overnight
    accommodations, at training sessions and competitions, and during travel to and from Special Olympics
    activities.

     

  • I agree

  •  4. Parent or Guardian Accompaniment. I understand that I must be accompanied by a Parent/Guardian in
    order for that person to take personal responsibility for me during a medical emergency in which I am
    unable to speak for myself.

  • I agree

  • 5. Emergency Medical Care If Athlete Is Not Accompanied. I understand that if I am not carrying the printed
    instructions or the accompanying Parent/Guardian is not present and actively taking personal
    responsibility for me during a medical emergency where I am unable to speak for myself, Special Olympics
    may seek emergency medical care for me as recommended by medical professionals responding to the
    emergency. I waive any claims against the Releasees should they seek emergency care for me.

  • I agree
  • Valid Emergency Care Refusal Form has been completed

  • Unfortunately, we cannot process your registration. Please be in touch with Special Olympics Vermont at 802-863-5222 or info@vtso.org for further support.

  •  SYMPTOMS FOR SPINAL CORD COMPRESSION and ATLANTOAXIAL INSTABILITY (For athletes 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.

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

    5.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.”

    6.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.

  • ATHLETE CODE OF CONDUCT AGREEMENT

  • I (and my parent/caregiver, if applicable) have read, understand, and agree to to following:

  • SPORTSMANSHIP & SAFE/APPROPRIATE BEHAVIOR

    • I will practice good sportsmanship for myself and toward all others
    • I will treat everyone equally, fairly, and with respect and dignity
    • I will only use respectful language. I will not swear, insult, brag or taunt other people- in-person or electronically
    • I will not fight, threaten, bully, harass, intimidate or harm anyone physically or electronically

  • TRAINING AND COMPETITION

    • I will train regularly and listen to my coaches and the officials
    • I will learn and follow the rules of my sport and ask questions when I do not understand
    • I will always try my best during training, divisioning and competitions
    • I will not “hold back” my qualifying performance just to get into an easier division

  • RESPONSIBILITY FOR MY ACTIONS

    • I will not initiate or engage (in-person or electronically) in any form of abuse towards anyone
    • I will be responsible for any electronic connections I make or interactions I have on my personal devices
    • I will not consume illegal or recreational drugs including but not limited to alcohol, tobacco, e-cigarette/vape products, or cannabis while representing Special Olympics at any event or for the purpose of improving my performance
    • I will obey all venue, local, and state/federal laws and Special Olympics rules and expectations

  • Athlete Signature (required for adult athlete with capacity to sign legal documents)

    I have read and understand this form. If I have questions, I will ask. By signing, I agree to this form.
  • Date (dd/mm/yyyy)
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  • PARENT/GUARDIAN SIGNATURE (required for athlete who is a minor or lacks capacity to sign legal documents)

    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.
  • Date (dd/mm/yyyy)
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