Special Olympics Missouri Athlete Registration Form

  • Athlete Registration Form

    Fill out the form carefully
  • Image field 127
  • I am a new Special Olympics Missouri athlete:*
  • Race/Ethnicity-Please check all that apply:*
  • Today Date
     - -
  • Language(s) Spoken by Athlete-Please check all that apply*
  • Current Employment Status of Athlete*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Associated Conditions Mandatory*
  • Assistive Devices and Accommodations-Do you use any of the following Check all that apply:*
  • Assistive Lifestyle Aids-Do you use any of the following Check all that apply:*
  • Assistive Communications-Do you use any of the following Check all that apply:*
  • Assistive Medical DevicesDo you use any of the following Check all that apply:*
  • Do you have a Specific Dietary requirement?*
  • Do you use other assistive device?*
  • Do you have a Heart Condition?*
  • Do you have asthma?*
  • 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?*
  • Has your Doctor ever limited your participation in Sports?*
  • Do you have epilepsy or any type of seizure disorder?*
  • Do you have sickle cell disease?*
  • Have you ever had a concussion?*
  • Date of last concussion (approximate)
     - -
  • Do you have behavioral, mental health, and /or sensory conditions?*
  • Do you have severe allergies that requires the use of EpiPen?*
  • If yes, please specify if it is to any of the following
  • 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.)*
  • Is this form being completed by someone other than the athlete?*
  • Relationship to Athlete:
  • 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).
  • 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?*

  • 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.

  • 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.

  • Submission Date*
     - -
  • Should be Empty: