Application For Participation (Medical Form) - Mississippi (Page 2 of 2) in pdf

OFFICIAL SPECIAL OLYMPICS RELEASE FORM

AREA:

SCHOOL/AGENCY:

ATHLETE NAME:

Last:

First:

DATE OF BIRTH:

month

day

year

I represent and warrant that to the best of my knowledge and belief, I (or my minor child) am (is) physically and mentally able to participate

in Special Olympics activities. I represent that I (or my minor child) meet eligibility requirement(s) for participation in Special Olympics by

having an intellectual and/or developmental disability. I also represent that a licensed physician has reviewed the health information

contained in my (or my minor child’s) application and has certified, based on an independent medical examination, that there is no medical

evidence which would preclude me (or my minor child) from participating in Special Olympics. I understand that if I (or my minor child) have

(has) Down Syndrome, I (or my minor child) cannot participate in sports or events which, by their nature, result in hyper-extension, radical

flexion or direct pressure on my (or my minor child’s) neck or upper spine unless I and two physicians have completed the official “Special

Release for Athletes with Atlanto-Axial Instability,” available from the Special Olympics Program in my area, or I (or my minor child) have

(has) had a a full radiological examination which establishes the absence of Atlanto-Axial 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-Axial Instability, I

(or my minor child) must have the radiological examination before I (or my minor child) can participate in equestrian sports, gymnastics,

diving, pentathlon, butterfly stroke, diving starts in swimming, high jump, alpine skiing, squat lift and football (soccer).

Special Olympics has my permission, (both during and anytime after), to use my (or my minor child’s) likeness, name, voice or words in

either 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.

TO BE COMPLETED BY

ADULT ATHLETE

PARENT/GUARDIAN OF MINOR ATHLETE

If a medical emergency should arise during the minor athlete’s

If, during my participation in Special Olympics activities, I should need

participation in any Special Olympics activities, at a time when I am not

emergency treatment, and I am not able to give my consent or make my

personally present so as to be consulted regarding the athlete’s care, I

own arrangements for that treatment because of my injuries, I authorize

hereby authorize Special Olympics, on my behalf, to take whatever

Special Olympics to take whatever measures are necessary to protect

measures are necessary to ensure that the athlete is provided with any

my health and well-being, including, if necessary, hospitalization.

emergency medical treatment, including hospitalization, which Special

Olympics deems advisable in order to protect the minor athlete’s health

I understand that it is my responsibility to acquire, review and complete

and well-being.

the Athlete Code of Conduct form for the safety and health of both myself

and my fellow athletes.

I understand that it is my responsibility to acquire, review and complete

the Athlete Code of Conduct form, with and for my athlete, for the safety

I am at least 18 years old and have submitted the attached application

and health of both my child and their fellow athletes.

for participation in Special Olympics. I have read this paper and fully

understand the provisions of the release that I am signing. I understand

I am the parent/guardian of the minor athlete named in this application.

that by signing this paper, I am saying that I agree to the provisions of this

I have read and fully understand the provisions of the above release, and

release.

have explained these provisions to the athlete. Through my signature on

this release form, I am agreeing to the above provisions on my own

behalf and on the behalf of the athlete named above. I hereby give my

Signature of Adult Athlete

Date

permission for the athlete named above to participate in Special

I hereby certify that I have reviewed this release with the athlete whose

Olympics games, recreation programs and physical activity programs.

signature appears above. I am satisfied, based on that review, that the

athlete understands this release and has agreed to its terms.

Signature of Parent/Guardian

Date

Name (print):

Relationship to athlete:

Special Olympics Mississippi has adopted guidelines for the housing of athletes at Special Olympics events. This policy is available for review at the

Chapter office. By signing below parents or guardians acknowledge that they were made aware that there is a policy available for review, if they wish.

Parent/Guardian

Date

Created by The Joseph P. Kennedy, Jr. Foundation for the Benefit of Persons with Intellectual Disabilities