Special Olympics Missouri Athlete Registration Form

Athlete Registration Form

Fill out the form carefully
Which AREA do you participate in:*
Coach's Name/SOMO Agency Name
Approver Email
example@example.com
I am a new Special Olympics Missouri athlete:*

YesNoNot sure
Athlete Name*

First NameMiddle NameLast NameSuffix (Jr., Sr., etc.)
Race/Ethnicity-Please check all that apply:*

American Indian/Alaskan NativeBlack/African AmericanWhite/CaucasianAsian AmericanHispanic/LatinoPrefer not to answerOther
Athlete Birth Date*

MonthDayYear
Athlete Gender*
Today Date

MonthDayYear
Date
Age Calculated
Language(s) Spoken by Athlete-Please check all that apply*

EnglishFrenchSpanishAmerican Sign Language(ASL)Other
Current Employment Status of Athlete*

Not WorkingFull-Time (30+ hours weekly)Part-Time (less than 30 hours weekly)
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Athlete E-mail
example@example.com
Mobile Number
Parent/Guardian Information - required if Minor or otherwise has a legal guardian

Parent/Guardian First NameParent/Guardian Last NameSuffix (Jr., Sr., etc.)
Parent/Guardian Address

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian Email
example@example.com
Phone Number
Please enter a valid phone number.
Emergency Contact:*

Emerg. Contact First NameEmerg. Contact Last NameSuffix (Jr., Sr., etc.)
Emergency Contact Phone Number*
Please enter a valid phone number.
Associated Conditions Mandatory*

AutismMarfan SyndromeCerebral PalsySpina BifidaDown SyndromeEpilepsyFetal Alcohol SyndromeFragile X SyndromeIntellectual DisabilityOther
Assistive Lifestyle Aids-Do you use any of the following Check all that apply:

CPAPDenturesGlasses, Contact Lenses, or protective eyewear
Assistive Devices and Accommodations-Do you use any of the following Check all that apply:

WalkerProstheticsBraces or CrutchesWheelchairRemovable Orthotics
Assistive Communications-Do you use any of the following Check all that apply:

Hearing AidsCommunication DevicesSign Language
Assistive Medical DevicesDo you use any of the following Check all that apply:

Implantable Cardioverter defibrillator(ICD)Implantable device for seizure managementVP ShuntPacemaker
Do you use other assistive device?*

YesNo
If Yes Please specify:
Do you have a Specific Dietary requirement?*

YesNo
If yes please be specify:
Do you have a Heart Condition?*

YesNO
Do you have a hearing impairment?*

YesNo
Do you have Diabetes that requires you to take insulin ?*

YesNo
Do you have a vision impairment?*

YesNo
Do you have a Bleeding disorder?*

YesNo
Has your Doctor ever limited your participation in Sports?*

YesNo
Do you have epilepsy or any type of seizure disorder?*

YesNo
Do you have sickle cell disease?*

yesNo
Have you ever had a concussion?*

YesNo
If yes please specify how many in your lifetime and date of last one
Do you have behavioral, mental health, and /or sensory conditions?*

YesNo
If yes, please specify:
Do you have severe allergies that requires the use of EpiPen?*

YesNo
If yes, please specify if it is to any of the following

Insect StingsFoodMedication/drugsLatexOther
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.)*

YesNo
Medication List (click SAVE to add additional row)
Name of Person Completing the form *
Is this form being completed by someone other than the athlete?*

YesNo
Relationship to Athlete:

Parent/GuardianCaregiverFamily MemberHealthcare providerCoachOther
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).

I have a religious or other objection to receiving medical treatmentI do not consent to blood transfusions.
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?*

YesNo
Upload athlete headshot*
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.
Athlete Signature

Clear
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.
Parent or Guardian Signature

Clear
Submission Date*

MonthDayYear
Date
Should be Empty: