Official Special Olympics Release Form

Download a blank fillable Official Special Olympics Release Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Official Special Olympics Release Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

O
S
O
R
F
FFICIAL
PECIAL
LYMPICS
ELEASE
ORM
Adult Athletes:
I ________________________________________________ am at least 18 years old and have submitted the attached application for participation
in Special Olympics Missouri.
Minor Athletes:
I am the parent/guardian of, __________________________________________ the minor athlete on whose behalf I have submitted the attached
application for participation in Special Olympics Missouri. I herby represent that the athlete has my permission to participate in Special Olympics
activities.
I or my athlete represent and warrant that, to the best of my knowledge and belief, I am/my athlete is physically and mentally able to participate in
Special Olympics activities. I/my athlete also represent that a licensed physician has reviewed the health information contained in my/my athlete’s
application and has certified, based on an independent medical examination, that there is no medical evidence which would preclude me/my
athlete from participating in Special Olympics. I understand that if I have/my athlete has Down Syndrome, I/my athlete cannot participate in sports
or events which, by their nature, result in hyper extension, radical flexion or direct pressure on I/my athlete’s neck or upper spine, unless I/my
athlete and two physicians have completed the official “Special Release for Athletes with Atlanto-Axial Instability,” available from the Special
Olympics Area program in my state, or I have/my athlete has had a full radiological examination which establishes the absence of Atlanto-Axis
instability. I am aware that if I choose not to complete the “Special Release for Athletes with Atlanto-Axial Instability” form which establishes the
absence of Atlanto-Axis instability, I/my athlete must have the radiological examination before I/my athlete can participate in equestrian, judo,
gymnastics, diving, butterfly stroke and diving starts, high jump, alpine skiing, snowboarding, squat lift and soccer.
Special Olympics has my/my athlete’s permission, both during and anytime after, to use my/my athlete’s likeness, name voice, or words in
television, radio film, newspapers, magazines, and other media, and in any form, for the purpose of advertising or communicating the purposes and
activities of Special Olympics and/or applying for funds to support these purposes and activities.
If, during my/my athlete’s participation in Special Olympics activities, I/my athlete should need emergency medical treatment, and I/my athlete is
not able to give my/my athlete’s consent or make my/my athlete’s own arrangements for treatment because of my/my athletes injuries, I/my
athlete authorize Special Olympics to take whatever measures are necessary to protect my/my athlete health and well-being, including, if
necessary, hospitalization.
I/my athlete, named above, has read this paper and fully understands the provisions of the release that I am/my athlete’s signing. I/my athlete
understand that by signing this paper, I am/my athlete is saying that I/my athlete agree to the provisions of this release.
Signature of Adult Athlete
Date
I herby Certify that I have reviewed this release with the athlete whose signature appears above. I am satisfied based on that review that the
athlete understands this release and has agreed to its terms.
Name:
Relationship to athlete:
I herby give my permission for the athlete named above to participate in Special Olympics games, recreation programs, and physical activity
program.
Signature of Parent/Guardian if athlete is under the age of 18
Date
A
-A
I
A
D
S
TLANTO
XIAL
NSTABILITY
SSESSMENT FOR ATHLETES WITH
OWN
YNDROME
Examiner’s note: If the athlete has Down Syndrome, Special Olympics requires a full radiological examination establishing the
absence of Atlanto-Axial Instability before she/he may participate in sports or events, which, by their nature, may result in
hyperextension, radical flexion or direct pressure on neck or upper spine. The sports and events for which such a radiological
examination is required are: equestrian, judo, gymnastics, diving, butterfly stroke and diving starts, high jump, alpine skiing,
snowboarding, squat lift and soccer.
Has an x-ray evaluation for atlanto-axial instability been done?
YES or NO
Date of X-ray ___/___/___
If yes, was it Positive for atlanto-axial instability?
YES or NO

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go