Application For Participation In Special Olympics Form

ADVERTISEMENT

APPLICATION FOR PARTICIPATION IN SPECIAL OLYMPICS
revised 1/18/08
BASIC INFORMATION
PROGRAM:
Male
Athlete’s Social Security #
-
-
(if US Citizen)
Date of Birth (month/day/year)
Female
_____/_____/_____
Athlete’s Name
Athlete’s Address
Home Phone #
Parent/Guardian’s Name
Work Phone #
Parent/Guardian’s Address (if different than athlete)
Home Phone #
Emergency Contact (if other than parent/guardian)
Home Phone #
Health/Accident Insurance Company
Policy #
HEALTH HISTORY: TO BE COMPLETED BY PARENT/CAREGIVER
Yes No
Yes No
*Heart disease / heart defect / high blood pressure
Allergy:
*Chest pain
Medicines:
*Seizures / epilepsy/ fainting spells
Food:
*Diabetes
Insect stings/bites:
*Concussion or serious head injury
Special diet
*Major surgery or serious illness
*Asthma
Heat stroke / exhaustion
Tobacco use
Visually impaired/contact lenses/glasses
Easy bleeding
*Blind
Emotional / psychiatric / behavioral
Hearing impaired
Sickle cell trait or disease
Deaf/Complete hearing loss
Immunizations up to date
Bone or joint problem
(for additional space, use back of
Other
form):
Date of most recent tetanus immunization ______/_____/_____
(*) Requires physical examination
Medications:
Please print medication name, amount, date prescribed and number of times per day medication is given.
Date
Date
Medication Name
Dosage
Prescribed.
Times per day
Medication Name
Dosage
Prescribed.
Times per day
Signature of parent/caregiver/adult athlete:
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: judo, equestrian sports, gymnastics, diving, pentathlon, butterfly stroke and
diving starts in swimming, high jump, alpine skiing, snowboarding, squat lift, and football team competition (soccer).
Yes No
Has an x-ray evaluation for atlanto-axial instability been done?
If yes, was it positive for atlanto-axial instability? (positive indicates that the atlanto-dens interval is 5mm or more)
PHYSICAL EXAMINATION
Blood pressure: _____/_____ Weight: _____ Height: _____
Normal/Abnormal
Normal/Abnormal
Normal/Abnormal
Vision
Cardiovascular system
Cranial nerves
Hearing
Respiratory system
Coordination
Oral cavity
Gastrointestinal system
Reflexes
Neck
Genitourinary system
Extremities
Skin
Other:
Primary MR Etiology/Category:
(If known)
_________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.
________ 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 not participate in Special Olympics.
RESTRICTIONS:
EXAMINER’S SIGNATURE:
Date
_____/_____/_____
EXAMINER’S NAME:
ADDRESS:
PHONE:

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 2