Application For Participation In Special Olympics Form
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APPLICATION FOR PARTICIPATION IN SPECIAL OLYMPICS UTAH
Clear Form
DEMOGRAPHICS
PROGRAM/TEAM
_______________________________________________________________
Athlete’s Name
Male
________________________________________
Female
Date of Birth (month/day/year) _____/_____/_____
Athlete’s Address
________________________________________
Athlete’s Home Phone #
(
) ________________________________________
City_______________
State_____________
Zip________________
Family E-mail
_____________________________________________
UT
Parent/Guardian Name
Parent/Guardian Phone #
(___)_________________________________________
________________________________________
Parent/Guardian Mobile #
(___)_________________________________________
Emergency Contact
________________________________________
Emergency Number
(___)_________________________________________
Athlete’s Health
Health Insurance
Insurance Co
________________________________________________________________
Policy #
____________________________
HEALTH HISTORY: TO BE COMPLETED BY PARENT/CAREGIVER
Yes No
Yes No
Heart disease / heart defect / high blood pressure
Allergy:
Chest pain
Medicines:
Seizures / epilepsy/fainting spells
Food:
Diabetes
Insect stings/bites:
Concussion or serious head injury
Special diet
Major surgery or serious illness Description:
Asthma
Heat stroke / exhaustion
Tobacco use
Blindness / visual problem
Easy bleeding
Contact lenses / glasses
Emotional / psychiatric / behavioral
Hearing loss / hearing aid
Sickle cell trait or disease
Bone or joint problem
Immunizations up to date
Utilizes Wheelchair
Electric____
Manual_____
Date of most recent tetanus immunization ______/_____/_____
Medications: Please print medication name, amount, date prescribed and number of times per day medication is given.
Date
Date
Medication Name
Dosage
Prescribed.
Times per day
Medication Name
Dosage
Prescribed.
Times per day
Type your name here to sign this document.
Signature of parent/caregiver/adult athlete:
date
_____/_____/_____
ATLANTO-AXIAL INSTABILITY ASSESSMENT FOR ATHLETES WITH DOWN SYNDROME
EXAMINER’S NOTE: If the athlete has Down syndrome, Special Olympics requires a full radiological examination establishing the absence of Atlanto-axial
Instability before he/she may participate in sports or events which, by their nature, may result in hyperextension, radical flexion or direct pressure on the neck or upper
spine. The sports and events for which such a radiological examination is required are: judo, equestrian sports, gymnastics, diving, pentathlon, butterfly stroke and
diving starts in swimming, high jump, alpine skiing, snowboarding, squat lift, and football team competition (soccer).
Yes No
N/A
Has an x-ray evaluation for atlanto-axial instability been done?
If yes, was it positive for atlanto-axial instability? (positive indicates that the atlanto-dens interval is 5mm or more)
PHYSICAL EXAMINATION
This form must be signed by a medical professional every 3 years.
Blood pressure: _____/_____ Weight: _____ Height: _____
Normal/Abnormal
Normal/Abnormal
Normal/Abnormal
Vision
Cardiovascular system
Cranial nerves
Hearing
Respiratory system
Coordination
Oral cavity
Gastrointestinal system
Reflexes
Neck
Genitourinary system
Extremities
Skin
Other:
Primary MR Etiology/Category (If known):
I have reviewed the above health information and have performed the above examination on this athlete within the past 6 months and certify that the
athlete can participate in Special Olympics.
RESTRICTIONS:
EXAMINER’S SIGNATURE:
Date
_____/_____/_____
EXAMINER’S NAME:
ADDRESS:
PHONE:
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