Application For Participation In Special Olympics Unified Sports Partner printable pdf download

APPLICATION FOR PARTICIPATION IN SPECIAL OLYMPICS

UNIFIED SPORTS

PARTNER

SECTION A – PARTNER INFORMATION

(Reverse side “Volunteer Registration Application” must be completed and signed)

PROGRAM_NAME:________________________________________________________________________________

Emergency Contact________________________________

Home Phone:____________________

Health/Accident Insurance Co._______________________

Policy #:________________________

(if Partner is under 18)

Parent/Guardian Name_____________________________

Home Phone:____________________

Address_________________________________________

Work Phone:_____________________

________________________________________________

Release and Waiver of Liability of Risk and Indemnity Agreement

In consideration of participating in Special Olympics Unified Sports

, I represent that I understand the nature of the

event and that I (and/or my minor child) am (are/is) qualified, in good health, and in proper physical condition to

participate in Unified Sports

events. I fully understand the event involves risks of serious bodily injury which may

be caused by my own action or inaction, by the actions of others participating in the event, or by conditions in which

the event takes place. I fully accept and assume all such risks and all responsibility for losses, costs, and/or

damages I (and/or my minor child) may incur as a result of my (and/or my minor child’s) participation. I

acknowledge that at any time that if I (we) feel that the event conditions are unsafe, I (and/or my minor child) will

discontinue participation immediately.

If during my participation in special Olympics activities I (and/or my minor child) should need emergency medical

treatment and I (and/or my minor child) am (are/is) not able to give consent or make own arrangements for that

treatment because of injuries, I authorize Special Olympics to take whatever measures are necessary to protect my

(and/or my minor child’s) health and well being, including, if necessary, hospitalization.

I (and/or my minor child) release, indemnify, covenant not to sue, and hold harmless Special Olympics, its

administrators, directors, agents, officers, volunteers, employees, and other Unified Sports

participants, and

sponsors, advertisers, and if applicable, any owners and lessors of premises on which the activity takes place from

all liability, any losses, claims (other than that of the medical accident benefit), demands, costs, or damages that I

(and/or my minor child) may incur as a result of participation in Unified Sports

events, and I further agree that if,

despite the “Release of Waiver of Liability Assumption of Risk and Indemnity Agreement”, I, or anyone on my behalf,

makes a claim against this Release, I will indemnify, save, and hold harmless this Release from any litigation

expenses, attorney fees, loss, liability, damage or costs which may incur as a result of such claim.

I have read this “Release of Waiver of Liability Assumption of Risk and Indemnity Agreement” and fully understand it.

Signature of Unified Sports

Partner

Date

Signature of Parent or Guardian if Unified Sports

Partner is a minor

Date

Created by the Joseph P. Kennedy, Jr. Foundation

Authorized and Accredited by Special Olympics, Inc.

For the Benefit of Persons with Mental Retardation

Application For Participation In Special Olympics Unified Sports Partner

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