Athlete Application For Participation In Special Olympics Maryland Form
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3ATHLETE APPLICATIO N FO R PARTICIPATIO N IN SPECIAL OLYM PICS MARYLAND
( v a l i d f o r 3 y e a r s )
COUNTY_______________________________________________ SOC. SEC #_________________________________________ DOB ________/_________/________
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FEMALE
or
MALE
ATHLETE or
PARTNER
NEW ATHLETE or
CURRENT
ATHLETE INFORMATION
PARENT / GUARDIAN INFORMATION
NAME _____________________________________________________________
NAME _____________________________________________________________
ADDRESS __________________________________________________________
ADDRESS __________________________________________________________
CITY/STATE/ZIP ____________________________________________________
CITY/STATE/ZIP ____________________________________________________
HOME PHONE (____ _) ___________________FAX (_ ____) ___________________
HOME PHONE (___ __) ___________________FAX (_ ____) ___________________
CELL PHONE ( _____) _________________________________________________
CELL PHONE (___ __) _________________________________________________
E-MAIL ____________________________________________________________
E-MAIL ____________________________________________________________
PARENT / GUARDIAN EMPLOYER
HEALTH/ACCIDENT INSURANCE CO ___________________________________
NAME______________________________________________________________
POLICY # __________________________________________________________
ETHNICITIES (OPTIONAL) CHECK ALL THAT APPLY:
ADDRESS__________________________________________________________
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CAUCASIAN
ASIAN AMERICAN
AFRICAN AMERICAN
CITY/STATE/ZIP _____________________________________________________
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MEXICAN
CARIBBEAN
HISPANIC
OTHER
PHONE (__ ___) ________________________FAX (___ __) ____________________
ATHLETE SCHOOL / AGENCY / EMPLOYER
EMERGENCY CONTACT (IF OTHER THAN PARENT)
NAME______________________________________________________________
ADDRESS__________________________________________________________
NAME______________________________________________________________
CITY/STATE/ZIP _____________________________________________________
PHONE (_ ____) ______________________________________________________
PHONE (____ _) ________________________FAX ( _____) ____________________
CELL PHONE (__ ___) _________________________________________________
HEALTH HISTORY: TO BE COMPLETED BY PARENT/CAREGIVER:
YES
NO
YES
NO
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*HEART DISEASE / HEART DEFECT / HIGH BLOOD PRESSURE
HEAT STROKE / EXHAUSTION
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*CHEST PAIN
FALSE TEETH / DENTURES
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*SEIZURES / EPILEPSY / FAITING SPELLS
TOBACCO USE
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*DIABETES
EASY BELEEDING
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*CONCUSSION OR SERIOUS HEAD INJURY
HEARING LOSS / SEVERE HEARING PROBLEM / HEARING AID
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*MAJOR SURGERY OR SERIOUS ILLNESS
CONTACT LENSES / GLASSES
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*BLINDNESS / SEVERE VISUAL PROBLEM
OTHER HEALTH ISSUES
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*ASTHMA
SPECIAL DIET (specify)
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SICKLE CELL TRAIT OR DISEASE
ALLERGY TO MEDICINES (specify)
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BONE OR JOINT PROBLEM
ALLERGY TO FOOD (specify)
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MISSING ONE KIDNEY
ALLERGY TO INSECT STING / BITE (specify)
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EMOTIONAL / PSYCHIATRIC / BEHAVIORAL PROBLEM
DATE OF LAST TETANUS SHOT __________________________
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HEPATITIS
ARE IMMUNIZATIONS UP TO DATE
YES
NO
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HAS ATHLETE EVER BEEN CHARGED / CONVICTED OF A CRIMINAL OFFENSE?
YES*
NO
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HAS ATHLETE EVER BEEN CHARGED WITH ABUSE OF ASSAULT?
YES*
NO
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DOES ATHLETE HAVE ANY PENDING CRIMINAL CASES?
YES*
NO
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IS ATHLETE NOW ON PROBATION FOR ANY CRIMINAL OR TRAFFIC VIOLATION?
YES*
NO
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HAS ATHLETE EVER BEEN FOUND “NOT CRIMINALLY RESPONSIBLE” FOR ANY CRIMINAL OR TRAFFIC OFFENSE?
YES*
NO
*ANSWERING ‘YES’ TO ANY OF THE ABOVE QUESTIONS DOES NOT EXCLUDE APPLICANT FROM PARTICIPATION IN SPECIAL OLYMPICS MARYLAND ACTIVITIES
*IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, PLEASE EXPLAIN THE DATES AND DETAILS OF EACH CASE ON A SEPARATE SHEET OF PAPER AND ATTACH TO THIS FORM
MEDICATIONS
(Attach separate form if necessary)
NAME OF MEDICATION
DOSAGE (MM)
TIMES PER DAY
DATE OF PRESCRIPTION
– PLEASE SIGN BELOW TO INDICATE THAT ALL OF THE ABOVE INFORMATION IS CORRECT, ACCURATE AND UP-TO-DATE
SIGNATURE
SIGNATURE OF PARENT/GUARDIAN/ADULT ATHLETE ________________________________________________________________________DATE ______/______/______
PLEASE COMPLETE SIDES TWO & THREE OF THIS APPLICATION
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