Special Olympics Hawaii Release For Athletes With Atlanto-Axial Instability Form
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1SPECIAL OLYMPICS HAWAII
RELEASE FOR ATHLETES WITH ATLANTO-AXIAL INSTABILITY
(Required for athletes diagnosed with Atlanto-Axial Instability)
Athlete Name_________________________________
Delegation________________________________
CERTIFICATION BY PHYSICIANS
We have examined the athlete named in the application, who has Down Syndrome and who has been diagnosed as having Atlanto-axial Instability.
We certify, based on our examinations of the athlete and our review of the health information contained in this application, that despite the diagnosis
of Atlanto-axial Instability, this athlete is not medically precluded from participation in Special Olympics. We further certify that we have explained
to the athlete named in this application, (and to the parent or guardian who signature appears below, if the athlete is a minor), the medical risks
associated with Atlanto-axial Instability and in particular, the risks associated with the athlete’s participation in sports or events which, by their
nature, may result in hyperextension, radical flexion or direct pressure on the neck or upper spine. (Signatures of two separate physicians are
required.)
Restriction (if any): _____________________________________
Restriction (if any): _____________________________________
Physician’s #1 name: ___________________________________
Physician’s #2 name: ___________________________________
Address: _____________________________________________
Address: _____________________________________________
_______________________Phone: ________________
____________________________Phone: ___________
Signature of Physician______________________Date_________
Signature of Physician______________________Date_________
CERTIFICATION OF ADULT ATHLETE
(Required for adult athletes with diagnosis of Atlanto-Axial Instability)
I am the athlete named in this application. I certify that,
1.
I have been informed by the physicians named above that I have Atlanto-Axial Instability.
2.
The risks associated with that condition, including the risks from participating in equestrian sports, gymnastics, diving, pentathlon, butterfly
stroke and diving starts in swimming, high jump, alpine skiing, and soccer have been fully explained to me by the physicians named above,
and I fully understand the possible medical consequences if I participate in any of these sports or events.
3.
Although I recognize and understand the risks and possible medical consequences, I certify that I am taking these risks knowingly and
voluntarily, of my own free will, because of my desire to participate in Special Olympics, including any or all of the sports listed above, based
on the certifications of the two physicians named above that I am not medically precluded from participating in Special Olympics.
Athlete Name: ___________________________________________________________________________________________________________
Address: _________________________________________________________________________________ Phone: ________________________
________________________________________________________________________________________
____________________________
Signature of Adult Athlete
Date
________________________________________________________________________________________
___________________________
Signature of Adult Friend or Family Member
Date
CERTIFICATION OF PARENT
(Required for minor athletes with diagnosis of Atlanto-Axial Instability)
I am the parent of the athlete named in this application. I certify that,
1.
I have been informed by the physicians named above that my son/daughter has Atlanto-Axial Instability.
2.
The risks associated with that condition, including the risks from participating in equestrian sports, gymnastics, diving, pentathlon, butterfly
stroke and diving starts in swimming, high jump, alpine skiing, and soccer have been fully explained to me by the physicians named above,
and I fully understand the possible medical consequences if my son/daughter participate in any of these sports or events.
3.
Although I recognize and understand the risks and possible medical consequences, I hereby give my permission for my son/daughter to
participate in Special Olympics, including any or all of the sports listed above, based on the certifications of the two physicians named above
that my son/daughter is not medically precluded from participating in Special Olympics.
Athlete Name:____________________________________________________________________________________________________________
Address: _________________________________________________________________________________ Phone: ________________________
________________________________________________________________________________________
____________________________
Signature of Parent/Guardian
Date
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