Unified Fishing Registration Form- Athlete

Athlete Name*

First NameLast Name

Athlete Birth Date*

MonthDayYear

Athlete Gender*

Athlete Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian/Staff Name- if athlete is a minor or requires guardianship or a staff, this person will be required to be in attendance.

First NameLast Name

Athlete, Parent, Staff, Guardian E-mail*

example@example.com

Athlete, Parent, Staff, Guardian Mobile Number*

Format: (000) 000-0000.

Which SOMO Team is the athlete a part of?*

Athlete's SOMO Coach*

First NameLast Name

Can the athlete swim?*

Would the athlete prefer to fish from a boat or from the bank?*

Life JacketFishing PoleLures/Bait/TackleNone of the above

If athlete has a request for a specific fisher/Unified Partner to be paired with, please list their name here:

I am the parent/guardian of the minor participant, on whose behalf I have submitted the attached application for participation in Special Olympics, or I am my own legal guardian. The participant has my permission to participate in Special Olympics activities. I further represent and warrant that to the best of my knowledge and belief, the participant is physically and mentally able to participate in Special Olympics.

In permitting the participant to participate, I am specifically granting my permission, forever, to Special Olympics to use the participant’s likeness, name, voice and words in television, radio, film, newspapers, magazines and other media, internet and in any form, for the purpose of publicizing, promoting or communicating the purposes and activities of Special Olympics and/or applying for funds to support those purposes and activities

If a medical emergency should arise during the participant’s participation in any Special Olympics activities, at a time when I am not personally present so as to be consulted regarding the participant’s care, I hereby authorize Special Olympics, on my behalf, to take whatever measures are necessary to ensure that the participant is provided with any emergency medical treatment, including hospitalization, which Special Olympics deems advisable in order to protect the participant’s health and well-being.

I am the parent (guardian) of the participant named in this application. I have read and fully understand the provisions of the above release, and have explained these provisions to the participant. Through my signature on this release form, I am agreeing to the above provisions on my own behalf and on the behalf of the participant named above. I hereby give my permission for the participant named above to participate in Special Olympics games, recreation programs, and physical activity programs.

Signature agreeing to the above statements:*

Today's Date*

Date

Athlete Registration Form