Application For Participation In Special Olympics Form printable pdf download

APPLICATION FOR PARTICIPATION IN SPECIAL OLYMPICS

(Physical Examination with Examiner’s signature required every 3 years)

BASIC INFORMATION

Delegation (Team) ___________________________________________________________________ Please print clearly. All information is required.

Name

Date of Birth

Phone #

Female

Male

Street Address or PO Box

Apt. #

State

ZIP Code + 4

City/Town

Emergency Contact Name

Emergency Contact Phone #

E thnicity (optional)

W hite

Hispanic/Latin

Black/African American

Native American

Other______________________

Asian

HEALTH HISTORY: TO BE COMPLETED BY PARENT/CAREGIVER

Y e s No

*Asthma

Heat stroke/exhaustion

Easy bleeding

Contact lenses/glasses

*Heart disease/heart defect

Allergies:

*High blood pressure

Hearing loss/hearing aid

Medicines:__________________________

*Chest pain

Bone or joint problem

Food:________________________________

*Seizures/epilepsy/fainting spells

Emotional/psychiatric/behavioral

Insect stings/bites:____________________

*Diabetes

Sickle cell trait or disease

Other Allergies________________________

Immunizations up to date

*Concussion or serious head injury

________________________________________

*Major surgery or serious illness

Special diet

(*) Requires physical examination

*Blindness/visual problem

Tobacco use

Down Syndrome**

**Must complete the Atlanto-Axial

Date of most recent tetanus immunization _____/_____/_____

Instability Assessment questionaire below

MEDICATIONS:

Please print medication name, amount, date prescribed and number of times per day mediation is given.

Date

Times

Medication Name

Dosage

Times

Dosage

Medication Name

Date

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

Has an x-ray evaluation for Atlanto-Axial Instability been done?

Date ___/___/___

If yes, was it positive for Atlanto-Axial Instability? (positive indicates that the atlanto-dens interval is 5mm or more)

If yes, you must complete the Special Release Form on the next page.

PHYSICAL EXAMINATION (to be completed by Health Professional)

Blood Pressure:_____/_____ Weight:______ Height:_____

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 (NO DOCTOR’S SIGNATURE STAMPS PLEASE)

RESTRICTIONS:_________________________________________________

EXAMINER’S NAME:_____________________________

EXAMINER’S SIGNATURE:___________________________________________

DATE: _____ / _____ / _____

ADDRESS:__________________________________________________________

PHONE:____________________________________