Athlete Application For Participation In Special Olympics Maryland Form Page 2

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APPLICATION FOR PARTICIPATIO N IN SPECIAL OLYMPICS MARYLAND / SIDE TWO

PHYSICAL EXAMINATION

ATHLETE NAME ____________________________________________________________________________________________________

BLOOD PRESSURE ________________________

HEIGHT _________ft _________inches

WEIGHT __________________lbs

PRIMARY ID ETIOLOGY/CATEGORY_________________________________________ IF PREGNANT, DUE DATE ______/_____/_____

NORMAL ABNORMAL

□

VISION

GARDIOVASCULAR SYSTEM

RESPIRATORY SYSTEM

NECK

□

HEARING

GENITO-URINARY SYSTEM

CRANIAL NERVES

SKIN

□

ORAL CAVITY

GASTROINTESTNAL SYSTEM

COORDINATION

REFLEXES

□

EXTREMITIES

COMMENTS ____________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________

RESTRICTIONS _________________________________________________________________________________________________________________________________

I AM A LICENSED MEDICAL PROFESSIONAL. I HAVE REVIEWED THE ACCOMPANYING HEALTH INFORMATION AND HAVE PERFORMED THE ABOVE EXAMINATION

ON THIS ATHLETE WITHIN THE LAST 6 MONTHS AND CERTIFY THAT THE ATHLETE CAN PARTICIPATE IN SPECIAL OLYMPICS.

EXAMINER’S NAME (Print or use Stamp) _______________________________________________________________ PHONE (______) _______________________________

ADDRESS ______________________________________________________________________________________________________________________________________

CITY/STATE/ZIP _________________________________________________________________________________________________________________________________

EXAMINER’S SIGNATURE ____________________________________________________________________________________________ DATE _______/_______/________

FOR ATHLETES WITH DOWN SYNDROME:

PERSONS WITH DOWN SYNDROME MUST HAVE A LATERAL X-RAY OF THE CERVICAL SPINE IN HYPERFLEXION AND HYPEREXTENSION. THE INTERPRETATION OF

THE RADIOGRAPHYS MUST INCLUDE MEASUREMENTS OF THE ATLANTO-DENS INTERVAL.

YES

□

HAS AN X-RAY EVALUATION FOR ATLANTOAXIAL INSTABILITY BEEN DONE?

IF YES, WAS THE ANTLANTO-DENS INTERVAL 5MM OR MORE?

OFFICIAL SPECIAL OLYMPICS RELEASE FO RM

I, ____________________________________________________________________________, am at least 18 years old and have submitted this application for participation in

Special Olympics.

I represent and warrant that, to the best of my knowledge and belief, I am physically and mentally able to participate in Special Olympics activities. I also represent that a licensed physician

has reviewed the health information contained in my application and has certified based on an independent medical examination, that there is no medical evidence which would preclude me

from participating in Special Olympics. I understand that if I have Down syndrome, I cannot participate in sports or events which by their nature result in hyper-extension, radical flexion or direct

pressure to my neck or upper spine unless I have a full radiological examination which established the absence of Atlanto-axial instability. I am aware that I must have this radiological

examination before I can participate in equestrian sports, gymnastics, diving, pentathlon, butterfly stroke, diving starts in swimming, high jump, alpine skiing and soccer.

Special Olympics has my permission, (both during and anytime after) to use my likeness, name, voice, or words in either television, radio, film, newspapers, magazines and other media, and

in any form, for the purpose of advertising or communicating the purposes and activities of Special Olympics and/or applying for funds to support those purposes and activities.

If, during my participation in Special Olympics activities, I should need emergency medical treatment, and I am not able to give my consent or make my own arrangements for treatment,

because of my injuries, I authorize Special Olympics to take whatever measures are necessary to protect my health and well-being, including, if necessary, hospitalization.

I, the athlete named above, have read this paper and fully understand the provisions of the release that I am signing. I understand that by signing this paper that I agree to the provisions of

this release.

Signature of adult athlete ____________________________________________________________________________________________________________ Date _________/__________/__________

I hereby certify that I have reviewed this release with the athlete whose signature appears above. I am satisfied based on that review that the athlete understands this release and has agreed

to the provisions of this release.

Name (print) _____________________________________________________________________________Relationship to athlete__________________________________________________________

I am the parent/guardian of __________________________________________________, the minor athlete, on whose behalf I have submitted this application for participation in

Special Olympics. I hereby represent that the athlete has my permission to participate in Special Olympics activities.

I further represent and warrant that, to the best of my knowledge and belief, the athlete is physically and mentally able to participate in Special Olympics. With my approval, a licensed

physician has reviewed the health information set forth in the athlete’s application and has certified based on an independent medical examination, that there is no medical evidence which

would preclude the athlete’s participation. I understand that if the athlete has Down syndrome, he/she cannot participate in sports or events which by their nature result in hyper-extension,

radical flexion or direct pressure to the neck or upper spine unless the athlete has a full radiological examination which establishes the absence of Atlanto-axial instability. I am aware that the

sports events for which this radiological examination is required are equestrian sports, gymnastics, diving, pentathlon, butterfly stroke, diving starts in swimming, high jump, alpine skiing and

soccer.

In permitting the athlete to participate, I am specifically granting my permission, (both during and anytime after) to special Olympics to use the athlete’s likeness, name;, voice, or words in

either television, radio, film, newspapers, magazines and other media, and in any form, for the purpose of advertising or communicating the purposes and activities of Special Olympics and/’or

applying for funds to support those purposes and activities.

If a medical emergency should arise during the athlete’s participation in any Special Olympics activities, at a time when I am not personally present so as to be consulted regarding the

athlete’s care, I hereby authorize Special Olympics to take whatever measures are necessary to ensure that the athlete is provided with any emergency medical treatment, including

hospitalization, which Special Olympics deems advisable in order to protect the athlete’s health and well-being.

I am the parent/guardian of the athlete named in this application. I have read and fully understand the provisions of the above release, and have explained these provisions to the athlete.

Through my signature on this release form, I am agreeing to the above provisions on my own behalf and on the behalf of the athlete named herein.

I hereby give my permission for the athlete named above to participate in Special Olympics Games, recreation programs and physical activity programs.

Signature of Parent/Guardian ________________________________________________________________________________________________________ Date __________/__________/__________

Name (print) _________________________________________________________________________________________________________________________________________________________