Application For Participation Form - Special Olympics Louisiana
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1Application for participation in Special Olympics Louisiana
(Licensed examiner signature required)
Demographics
Please select one: o New Athlete o Renewal
Special Olympics Louisiana Area: _____________________________________
Athlete’s First Name: ______________________________________ MI ______ Last Name: ________________________________________
Athlete’s Social Security #: ___________-_________-____________
Gender: o M o F
Date of Birth: ________/_______/____________
Athlete’s Address: __________________________________________________ City______________________ State _____ Zip___________
Athlete Email Address: __________________________________________ Place of Employment: ___________________________________
Athlete Phone #: (__________)_____________-________________ Phone # Type: o Mobile o Home o Other__________________________
Health Insurance Provider _______________________________________________ Policy #: ______________________________________
Parent/Guardian’s First Name: _____________________________________ Last Name: ___________________________________________
Parent/Guardian’s Address: ______________________________________________ City: _____________________State_____ Zip________
Parent’s Email Address: _______________________________________________________________________________________________
Parent’s Home Phone # :(___________)_____________-_______________ Parent’s Mobile Phone #: (_________)_________-_____________
Emergency Contact Name: ____________________________________ Emergency Contact Phone #:(_________)_________-_____________
Health History (to be completed by parent/guardian or caregiver)
* These items require an annual physical examination
Yes No
Yes
No
*Heart disease / heart defect / high blood pressure
Allergy: ____________________________________
*Chest pain
Medicine Allergy:________________________
*Seizures / epilepsy/fainting spells
Food Allergy:___________________________
*Diabetes
Insect sting/bite Allergy:__________________
*Concussion or serious head injury
Special diet: ________________________________
*Major surgery or serious illness ____________________
Tobacco use
*Asthma
Easy bleeding/ history of blood disorders
*Blindness / visual problem
Emotional / psychiatric / behavioral
Contact lenses / glasses
Down Syndrome**
(See Atlanto-Axial Instability Assessment)
Hearing loss / hearing aid
Sickle cell trait or disease
Heat stroke / exhaustion
Immunizations up to date, including tetanus
Wheelchair/Walker (please circle one if applicable)
Date of most recent tetanus immunization _____/_______/______
Bone or joint problem
Other:
__________________________
(use back if needed)
Medications:
Please print medication name, dosage, date prescribed and number of times per day medication is given. Use back if needed.
Medication Name
Dosage
Date Prescribed
Times Per Day
Medication Name
Dosage
Date Prescribed
Times Per Day
Signature of Parent/Guardian or Caregiver: _____________________________________________________ Date: _____/_______/______
**Atlanto-Axial Instability Assessment for Athletes with Down Syndrome
EXAMINER’S NOTE: If the Athlete has Down Syndrome, Special Olympics requires a full radiological examination establishing the absence of
Atlanto-axial Instability before he/she may participate in sports or events which, by their nature, may result in hyperextension, radical flexion or
direct pressure on the neck or upper spine. The sports and events for which such a radiological examination is required are: butterfly events,
individual medley events and diving starts in swimming, diving, pentathlon, high jump, equestrian sports, artistic gymnastics, football (soccer)
team competition, squat lift, snowboarding, judo, alpine skiing and any warm-up exercise placing undue stress on the head and neck.
Yes
No
Has an x-ray evaluation for atlanto-axial instability been done?
Date: _____/_______/______
If yes, was it positive for atlanto-axial instability? (positive indicates that the atlanto-dens interval is 5mm or more)
Physical Examination (to be completed by health care professional)
Blood Pressure: ____________/_______________
Weight:________________
Height: ________________
Normal
Abnormal
Normal
Abnormal
Normal
Abnormal
Vision
Cardiovascular system
Skin
Hearing
Respiratory system
Cranial nerves
Oral Cavity
Gastrointestinal system
Coordination
Neck
Genitourinary system
Reflexes
Extremities
Other: ________________________________________ Primary MR Etiology/Category: (if known)____________________________________
Restrictions: ________________________________________________________________________________________________________
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 Louisiana.
Examiner’s Name: ___________________________________________________ Examiner’s Phone #: (_______)_________-_____________
Examiner’s Address: _________________________________________________ City:_____________________ State:_____ Zip:__________
Examiner’s Signature:________________________________________________________________________ Date: _____/_______/_____
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