Application For Participation In Special Olympics Minnesota Form
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ApplicAtion for pArticipAtion in speciAl olympics minnesotA
Please print clearly and complete all sections in their entirety.
State Office ONLY:
This application expires three (3) years from the date of exam.
Delegation:
People are eligible for Special Olympics provided they are age 8 or above and are considered to have
an intellectual disability or closely related developmental disability, defined as functional limitations
Updated Form
in both general learning and two or more adaptive skill areas: communication, leisure, self-direction,
New Athlete
home living, community use, work, health and safety, academics, self-care and social skills.
in GMS
not in GMS
Send completed forms to: SOMN, 100 Washington Ave S., Suite 550, Minneapolis, MN 55401
Email:
Fax: 612.333.8782
Section a: demographicS
Delegation:
Male
Female
Date of Birth
/
/
:
Athlete Name:
Athlete Primary Phone: (
)
Athlete Address:
(Circle one) home
work
cell
Athlete Email:
City:
State:
Zip:
Parent/Guardian Name:
Parent Primary Phone: (
)
(Circle one) home
work
cell
Parent/Guardian Address
(if different than athlete):
Parent Alternate Phone: (
)
(Circle one) home
work
cell
City:
State:
Zip:
Parent Email:
Emergency Contact
Emergency Contact Phone: (
)
(if other than Parent/Guardian):
(Circle one) home
work
cell
Emergency Contact
Health/Accident Insurance Company:
Relationship to Athlete:
Policy #:
Section b: health hiStory (may be completed by parent/GUardian)
Yes
No
Please indicate “yes” or “no” for all areas
Heat Stroke/Exhaustion
Yes
No
Immunizations up-to-date
Allergies: __________________________________________
Major Surgery or Serious Illness ______________________
Asthma
Non-verbal
Blindness/Visual Problems (other than corrective lenses)
Seizures/Epilepsy/Fainting Spells
Bone or Joint Problem
Sickle Cell Trait or Disease
Chest Pain
Special Diet _______________________________________
Concussion or Serious Head Injury:_____________________
Uses Tobacco
Contact Lenses/Glasses
Uses Wheelchair
Diabetes
Other: ___________________________________________
Down Syndrome (If Yes, see next page)
(for additional space, please see reverse side)
Easy Bleeding
Have you ever been convicted of a criminal offense?*
Emotional/Psychiatric/Behavioral Problems
Have you ever been charged with neglect, abuse or assault?*
Hearing Loss/Hearing Aid
(see below)
*If yes, providing your Social Security Number:
Heart Disease/Heart Defect/High Blood Pressure
______ - ____ - ______ will give Special Olympics Minnesota
consent to run a background check.
Medications:
None
Listed Below
Medication Name
Dosage
Date Prescribed
Times per day
Medication Name
Dosage
Date Prescribed
Times per day
Signature
Signature of Parent/Guardian _____________________________________________________ Date: _____ / _____ / _____
• R e q u i R e d •
Required. Athletes can sign if they are their own guardian.
Printed Name _________________________________________ Relationship to Athlete _____________________________
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