Application For Participation (Medical Form) - Special Olympics - Florida
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1
2Circle One
APPLICATION FOR PARTICIPATION (Medical Form)
NEW
RENEWAL
(must be completed and signed by licensed examiner every 3 years)
R
__________________________
COUNTY
School/Agency:
E
Q
/
/
SSN:
T-shirt Size:
Children:
OR
Adult:
U
SEX/DATE OF BIRTH (
)
LAST NAME
FIRST
REQUIRED
I
M or F
month/day/year
R
Street Number/Address
/
/
E
D
City
State ________ Zip Code
Email ____________________________________
Parent/Guardian
Cell Phone (
)
_________________________
Address (if different)
Home Phone (
)
City
State
Zip Code
P/G Email ________________________________________________
Emergency Contact (other than parent/guardian)
Emerg. Phone (
)
Health Insurance Company
Ins. Policy #
REQUIRED
Signature of parent/legal guardian/adult athlete completing form
_______
REQUIRED
ALSO PRINT NAME _________________________________________________________
FOR ATHLETES WITH DOWN SYNDROME
--
Persons with Down syndrome should have a lateral x-ray of the cervical spine in hyperflexion and
hyperextension. The interpretation of the radiographs should include measurements of the atlanto-dens interval.
Yes No
Has an x-ray evaluation for atlantoaxial instability been done?
Yes No
If yes, was it positive for atlantoaxial instability? (positive indicates that the atlanto-dens interval is 5mm or more)
IS THERE PRESENT OR A HISTORY OF (to be completed by parent/caregiver):
Blind
Yes
Tobacco use
Yes
Emotional/psychiatric/behavioral problems
Yes
Deaf
Yes
Major surgery or serious illness
Yes
Asthma/breathing problems with exertion
Yes
Heart problems/high blood pressure
Yes
Heat stroke/exhaustion
Yes
Contact lenses/glasses/dentures/false teeth
Yes
Seizures/epilepsy/fainting spells
Yes
Easy bleeding
Yes
Head injury/history of concussion
Yes
Diabetes
Yes
Bone/joint problems
Yes
Immunizations (shots) are up-to-date
Yes
Hearing aid/hearing problems
Yes
Sickle cell disease or trait
Yes
Special Diet Needs (list below)
Yes
Blindness/vision problem
Yes
Uses a wheelchair
Yes
Year of last tetanus shot
Other problems that would interfere with participation
Allergy to the following (list specific):
Food
Insect sting/bites
Medication
MEDICATIONS
Medication Name
Dosage
Date Presc.
Times per day
Medication Name
Dosage
Date Presc.
Times per day
PHYSICAL EXAMINATION
Normal Abnormal
Normal Abnormal
Normal
Abnormal
Blood Pressure _____
Vision
Oral Cavity
Cardiovascular system
Pulse
_____
Hearing
Extremities
Respiratory system
Weight
_____
Neck
Coordination
Gastrointestinal system
Height
Skin
Reflexes
Genitourinary system
_____
Cranial nerves
Other:
Primary MR Etiology/Category
I have reviewed the above health information and examined the athlete named in the application and certify that there is no medical evidence available to me which would preclude
the athlete’s participation in Special Olympics.
Restrictions
REQUIRED
Examiner’s Name:
Certification: MD
DO DC PA
ARNP
REQUIRED
REQUIRED
EXAMINER’S SIGNATURE
DATE:
OPTIONAL INFORMATION
Ethnic background:
Asian African American
Caucasian
Hispanic
Native American
Other
Rev. 5-2013
Special Olympics Florida Sports Information Guide 2015-2016
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Parent category: Medical