Application For Participation In Special Olympics Form
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1
2APPLICATION FOR PARTICIPATION IN SPECIAL OLYMPICS
[ ] Check If NEW Athlete (Never participated in Special Olympics before)
ELIGIBILITY FOR PARTICIPATION IN SPECIAL OLYMPICS: Every person with Intellectual Disabilities is eligible to participate in Special Olympics. A
person is considered to have Intellectual Disabilities if that person satisfies any one of the following requirements: 1) person has been identified by an
agency or professional as having Intellectual Disabilities, 2) person has a cognitive delay, as determined by standardized measures such as intelligent
quotient or “IQ” testing or other measures which are generally accepted as being a reliable measurement of the existence of a cognitive delay, or 3)
person has a closely related developmental disability. A “closely related developmental disability” means having functional limitations in both general
learning (such as IQ) and in adaptive skills (such as in recreation, work, independent living, or self-care). Persons whose functional limitations are based
solely on a physical, behavioral, emotional disability, or a specific learning or sensory disability are not eligible to participate in Special Olympics.
SECTION A – ATHLETE INFORMATION
Required once every three (3) years for all athletes.
Please print clearly in blue or black ink.
REGION/AREA/LOCAL PROGRAM: _________________________________________ YEAR STARTED IN SPECIAL OLYMPICS: _____________
ATHLETE INFORMATION
ATHLETE NAME: (LAST)_________________________________ (FIRST)_________________________________
(NICKNAME)___________________________
DATE OF BIRTH (month/day/year): ________ / ________ / ________
GENDER (circle):
Male
Female
ADDRESS: __________________________________________________(APT/STE)_______
HOME PHONE: (________) __________________________
CITY: _________________________________________ STATE: ________ ZIP: _________
MOBILE PHONE: (________)__________________________
EMAIL: ____________________________________________
HEALTH INSURANCE COMPANY: ________________________________________________
POLICY #: __________________________________________
ETHNIC BACKGROUND: African Amer.
[ ] Anglo
[ ] Asian/Pacific Islands
[ ] Hispanic
[ ] Native Amer.
[ ]
Other not listed
[ ] _________________
ATHLETE EMPLOYMENT INFORMATION
EMPLOYER: ________________________________________________________________
WORK PHONE: (________)__________________________
ADDRESS: _________________________________________________________________
CITY: _________________________________________ STATE: _______ ZIP: _________
PARENT/GUARDIAN INFORMATION
PARENT/GUARDIAN NAME: _________________________________________________
HOME PHONE:
(________) ________________________
ADDRESS: _______________________________________________________________
MOBILE PHONE:
(________) ________________________
CITY: _________________________________________ STATE: ______ ZIP: _________
WORK PHONE:
(________) ________________________
EMAIL: ______________________________________________
PARENT/GUARDIAN EMPLOYMENT INFORMATION
EMPLOYER: ______________________________________________________________
EMPLOYER PHONE: (________)________________________
ADDRESS: _______________________________________________________________
CITY: _________________________________________ STATE: _______ Zip: _________
EMERGENCY CONTACT INFORMATION
CONTACT: _______________________________________________________________
RELATIONSHIP: _____________________________________
HOME PHONE:
(________) ________________________
MOBILE PHONE:
(________) ________________________
FOR OFFICE USE ONLY
Date Received: _______________________________________
Verified by: ___________________________________________
UPDATED 2012
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Application for Participation in Special Olympics
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