Official Special Olympics Consent Form

OFFICIAL SPECIAL OLYMPICS CONSENT FORM

Athlete Name: First

_______Last

_______________

D.O.B.:

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RELEASE TO BE COMPLETED BY PARENT/GUARDIAN OR ADULT ATHLETE (OWN GUARDIAN)

THIS FORM MUST BE COMPLETED LEGIBLY, SIGNED, AND DATED TO BE CONSIDERED VALID FOR THREE (3) YEARS

I, the Parent/Guardian or Adult Athlete submits this Official Special Olympics Release Form for participation in Special Olympics.

Section 1

I represent and warrant that, to the best of my knowledge and belief, the athlete is physically and mentally able to participate in Special Olympics activities. I also represent that a

licensed medical examiner (MD/DO/NP/PA-C) has reviewed the health information contained in the application for participation and has certified, based on a medical examination, that

there is no medical evidence which would preclude the athlete from participating in Special Olympics.

Section 2

I understand that if the athlete has Down syndrome, the athlete cannot participate in sports or events which by their nature result in hyper-extension, radical flexion or direct pressure on

the neck or upper spine unless the athlete and medical examiner have completed the official “Down syndrome Addendum Form”, available from the Special Olympics State Office. I am

aware that the x-ray exam is required before any athlete with Down syndrome may participate in equestrian, gymnastics, judo, diving, pentathlon, butterfly stroke, diving starts in

swimming, high jump, alpine skiing, snowboarding, squat lift, and soccer.

Section 3

Special Olympics has my permission, both during and any time after, to use the athlete’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 those purposes and

activities.

Section 4

If during the athlete’s participation in Special Olympics activities, the athlete should need emergency medical treatment, and I (the parent/guardian or adult athlete) am not able to give

consent or make arrangements for that treatment, I authorize Special Olympics to take whatever measures necessary to protect the athlete’s health and well-being, including if

necessary, hospitalization.

Section 5

I understand by signing below, that I consent to participate in the Special Olympics Healthy Athletes Program that provides individuals screening assessments of health status and

health care needs in the areas of vision, oral health, hearing, physical therapy, and a variety of health promotion areas. I understand there is no obligation for the athlete to participate in

the Healthy Athletes Program and that the athlete may decide not to participate. Provisions of these health services are not intended as a substitute for regular care. I also understand

that I should seek independent medical advice and assistance irrespective of the provisions of these services and that Special Olympics is not responsible for the health of the athlete. I

understand that information gathered as part of the screening process may be used anonymously to assess and communicate overall health and needs of athletes and to develop

programs to address those needs.

Section 6

I understand the nature and risk of concussion and head injuries, including the risks of continuing to play after concussion or head injury. I acknowledge that Special Olympics has a

concussion awareness and safety recognition policy that may require an athlete to seek medical attention from a medical professional in the event of a suspected concussion. Any

athlete suspected of sustaining a concussion will not be permitted to return to Special Olympics sports activities until written medical clearance is provided and at least 7 days have

passed following from the date of suspected injury. I further acknowledge that additional information regarding concussions may be found on the Centers for Disease Control Heads Up

website at

OR

To be completed by Adult Athlete (own Guardian)

To be completed by Parent/Guardian

I, the adult athlete, have read this form and fully understand the provisions of the

I, the Parent/Guardian of this athlete, hereby give my permission for this athlete

release that I am signing. I acknowledge that I have read and agree to the Athlete

to participate in Special Olympics games, training, recreation programs, physical

Code of Conduct and the Code of Conduct Compliance Policy. I understand that

activity programs and Healthy Athletes program. I acknowledge I have read and

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

agree to the Athlete Code of Conduct and the Code of Conduct Compliance

Policy. By signing, I am saying that I agree to the provisions of this release.

Signature __________________________________________

Print Name ________________________________________

Signature __________________________________________

Date: _____/_____/_____

Print Name _________________________________________

Date: _____/_____/_____

I hereby 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.

Signature __________________________________________

Print Name ________________________________________

Date: _____/_____/_____