Application For Participation In Special Olympics Missouri Form
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1Application for participation in Special Olympics Missouri
Physical examination required every 3 years
Please Print
Agency Name and Number
New Athlete Yes or No
First
MI
Last
Gender: Male
Female
Athlete's SSN
-
-
Date of Birth
/
/
Athlete’s E-mail address
Athlete's Address (Complete)______________________________________City
State_____ Zip__________ Phone (
)_______________________Cell Phone(
)
Parent /Guardian Name
Parent/Guardian E-mail address
Parent/Guardian Address (Complete)___________________________________________ City
Zip__________ Phone (
)___________________________Cell Phone(
)
Emergency Contact Person ________________________________________ Phone (
)
Health Insurance Company___________________________________________ Medicaid
Health History
Circle One
Circle One
1.
Heart Disease/heart defect/chest pain
yes
no
11. Hearing loss/hearing aid
yes
no
2.
High blood pressure
yes
no
12. Special Diet
yes
no
3.
Seizures/epilepsy/fainting spells
yes
no
13. Asthma
yes
no
4.
Diabetes
yes
no
14. Easy Bleeding
yes
no
5.
Concussion or serious head injury
yes
no
15. Emotional/psychiatric/behavioral yes
no
6.
Major Surgery or Serious illness
yes
no
16. Sickle cell trait or disease
yes
no
7.
Heat Stroke/exhaustion
yes
no
17. Immunization up to date
yes
no
8.
Blindness/visual problem
yes
no
18. Bone or joint problems
yes
no
9.
Contact lenses/glasses
yes
no
19. Down Syndrome
yes
no
Allergies
Please print medication name, amount, date prescribed and number of times per day medication is given. Attach extra sheet of
paper if needed.
Signature of parent/caregiver/adult athlete
Physical Examination
Blood Pressure
/
Weight
Height_________
Normal(N)Abnormal(A)
Normal (N) Abnormal(A)
Normal(N) Abnormal(A)
Vision
N
A
Cardiovascular System
N
A
Cranial Nerves
N
A
Hearing
N
A
Respiratory System
N
A
Coordination
N
A
Oral Cavity N
A
Gastrointestinal System
N
A
Reflexes
N
A
Neck
N
A
Genitourinary System
N
A
Skin
N
A
Extremities N
A
Other:
Primary MR Etiology/Category
Restrictions:
Examiner’s Name:
Address:
City
Zip code
Phone
Examiner’s Signature
Date
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 Missouri.
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