Application For Participation In Special Olympics Iowa Form printable pdf download

APPLICATION FOR PARTICIPATION IN SPECIAL OLYMPICS IOWA

PLEASE PRINT LEGIBLY

Athlete Name____________________________________________________________ Delegation (

) __________________________________________________

School/Facility

Birthdate _________________________________ Gender ________________________ Parent/Guardian (

) _________________________________________________

Circle One

Athlete Phone (_______________)____________________________________________ Parent/Guardian Phone (_______________)____________________________________

Athlete Address___________________________________________________________ Parent Address ___________________________________________________________

City __________________________________ State __________ Zip _______________City _________________________________ State ___________ Zip _______________

HEALTH INSURANCE & EMERGENCY INFORMATION

Emergency Contact __________________________________________________

Emergency Contact Phone (____________)________________________

Medical Insurance ___________________________________________________

Policy Number _______________________________________________

MEDICAL CLEARANCE

Does athlete have Down Syndrome?

YES

If yes, have x-rays of the C1-C2 vertebrae been taken and examined?

YES

Date of x-ray _______________________________

Atlantoaxial Instability:

Positive AA

Negative AA

YES NO

Blood Pressure ___________________ Height __________________ Weight _________________

Heart Problems

Blind

Date of last Tetanus shot ___________________ Allergies __________________________________________________

Epileptic/Seizures

Deaf

Diabetes

Asthma

Other Conditions ____________________________________________________________________________________

Use Wheelchair

Hepatitis

Current Medication (List)

Dosage

Current Medication (List)

Dosage

_____________________________________________________________

____________________________________________________________

_____________________________________________________________

____________________________________________________________

I have examined the above-named Athlete and, in my opinion, there is no mental or physical reason why he or she should not participate in Special Olympics sports training

and competition. Further information will be forwarded if required. Current medication, if any, is specified with dosage on this application.

Sports athlete is NOT allowed to participate in: _________________________________________________________________________________________________

Practitioner’s Printed Name ______________________________________________________ Practitioner’s Signature ________________________________ Exam Date __________________

Address ________________________________________________ City _________________________ State ________ Zip ______________ Phone (__________)_______________________

*Acceptable signatures are licensed physician and surgeon, osteopathic physician and surgeon, osteopath, advanced registered nurse practitioner (ARNP), physician's assistant or qualified doctor of chiropractic.

PARENT AND/OR GUARDIAN AUTHORIZATION & MEDIA RELEASE

I, on my own behalf or as the undersigned parent or legal guardian of the above named applicant (hereafter referred to as the "Athlete"), hereby give permission for the Athlete to participate

in Special Olympics programs. I acknowledge that Special Olympics will screen all athletes using the Sex Offender Public Registry and understand that athletes listed on the Registry will be

denied participation. I affirm that this Athlete has never been on said Registry or, if Athlete was listed on the Sex Offender Public Registry but has since been removed I will contact Special

Olympics Iowa for instructions before submitting this application. I represent and warrant that the Athlete is physically and mentally able to participate in Special Olympics. 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 pressure on the neck or upper spine unless a

full radiological examination establishes the absence of Atlantoaxial Instability. I am aware that sports and events for which this radiological examination is required are equestrian sports,

artistic gymnastics, diving, pentathlon, high jump, alpine skiing, soccer, soccer skills, powerlifting squat and butterfly stroke and diving starts in swimming. On behalf of the Athlete and myself,

I acknowledge that the Athlete will be using facilities at his/her own risk and I, on my own behalf, hereby release, discharge and indemnify Special Olympics from all liability for injury to person

or damage to property of myself and Athlete. In permitting the Athlete to participate, I am specifically granting permission to Special Olympics Iowa to use the likeness, voice and words of the

Athlete in television, radio, films, newspapers, magazines and other media, and in any form not heretofore described, for the purpose of advertising or communicating the purposes and activities

of Special Olympics and in appealing for funds to support such activities. I understand that by signing below I consent for the Athlete to participate in the Special Olympics Healthy Athletes

Program that provides individual screening assessments of health status and health care needs. The Athlete has no obligation to participate and I understand the Athlete should seek his/her

own medical advice and assistance and Special Olympics is not responsible for the Athlete's health. If I am not personally present at Special Olympics activities in which the Athlete is

to compete, so as to be consulted in case of necessity, you are authorized on my behalf and at my account to take such measures and arrange for such medical and hospital treatment as you

may deem advisable for the health and well-being of the Athlete. Housing Policy: “I acknowledge that Special Olympics events may involve overnight activities and that housing arrangements for

each event may differ. I understand that I should contact my State Program Office if I have any questions about housing arrangements for a specific event or the housing policy in general.”

I, THE UNDERSIGNED ADULT ATHLETE, have read and fully

I, THE UNDERSIGNED PARENT AND/OR GUARDIAN of the above specified Athlete, have read and

understand the provisions of the above release and/or have had them

fully understand the provisions of the above release and have explained them to the Athlete. I hereby

explained. I hereby agree that I will be bound thereby and I shall defend

agree that I and said Athlete will be bound thereby, and I shall defend Special Olympics Iowa and hold

Special Olympics Iowa and hold it harmless from disaffirmation thereof.

it harmless from any disaffirmation thereof by said Athlete.

Signature of Parent

Athlete Signature ______________________________________

and/or Legal Guardian __________________________________________________

Witness ___________________________ Date _____________