Application For Participation In Special Olympics Form, Official Special Olympics Release Form (Page 4 of 4) in pdf

Application For Participation In Special Olympics Form, Official Special Olympics Release Form Page 4

ATHLETE VOLUNTEER SCREENING INFORMATION

Only to be completed if athlete is serving in a volunteer capacity (i.e. Global Messenger, speech coach, sport coach, etc.)

Check yes or no to the following questions:

†

1. Do you use illegal drugs?

yes

_____ no _____

†

2. Have you ever been convicted of a criminal offense?

yes

_____ no _____

†

3. Have you ever been charged with neglect, abuse or assault?

yes

_____ no _____

†

4. Has your driver’s license ever been suspended or revoked in any state?

yes

_____ no _____

†

If you answered “yes” to any question, attach an explanation giving date, location and nature of disposition for any offense.

A conviction will not necessarily disqualify you from volunteering with Special Olympics North Carolina.

Please read before signing

I understand that some of the information that I have provided may be verified, and I give permission to Special Olympics to check my

references and to make inquiry of others including without limitation my employer concerning my background and suitability to act as

a Special Olympics volunteer.

I affirm that I have read the above and that the information I have given is true and complete.

Print name ________________________________ Signature ___________________________________ Date _________

Initial One:

Volunteer is at least eighteen (18) years of age and executes this release on his/her own behalf _________

Volunteer is less than eighteen (18) years of age. The undersigned is the _____ parent ____ legal guardian (initial one) of the volunteer

and executes this Release on behalf of the volunteer.

Print name ________________________________ Signature ___________________________________ Date _________

Parent/Guardian Name

Parent/Guardian Signature

Application For Participation In Special Olympics Form, Official Special Olympics Release Form Page 4