Application For Participation In Special Olympics Form (Page 2 of 2) in pdf

OFFICIAL SPECIAL OLYMPICS RELEASE FORM

RELEASE TO BE COMPLETED BY ADULT ATHLETE

am at least 18 years old and have submitted the attached 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 on my neck or upper spine unless I and two physicians have

completed the official “Special Release for Athletes with Atlanto-Axial Instability,” available from the Special Olympics Chapter program in my state, or I have had a

full radiological examination which establishes the absence of Atlanto-axial Instability. I am aware that if I choose not to complete the “Special Release for Athletes

with Atlanto-Axial Instability” form which establishes the absence of Atlanto-axial Instability, I must have the radiological examination before I can participate in

judo, equestrian sports, gymnastics, diving, pentathlon, butterfly stroke, diving starts in swimming, high jump, alpine skiing, snowboarding, squat lift and football

team competition (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 these 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 that 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 understand that by signing below I consent to participate in the Special Olympics Healthy Athletes Program that provides individual screening

assessments of the health status and health care needs in the areas of: vision; oral health; hearing; podiatry; physical therapy; and a variety of health promotion

areas (height, weight, sun protection, etc.). I understand that participation in the Healthy Athletes Program is voluntary and that I may decide not to participate. I

understand that provision of these health services is not intended as a substitute for regular health care and that I should seek my own independent medical

advice and assistance irrespective of the provision of these services. Neither Special Olympics, Inc. nor Special Olympics Montana through the provision of these

services are responsible for my health or my health care.

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, I am saying 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 its terms.

Name:

Relationship to athlete:

(e.g. family member, teacher, coach, etc.)

RELEASE TO BE COMPLETED BY PARENT OR GUARDIAN OF MINOR ATHLETE

I am the parent/guardian of

, the minor athlete, on whose behalf I have submitted the attached 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 on the neck or upper spine, unless I

and two physicians have completed the official “Special Release for Athletes with Atlanto-Axial Instability.” Available from the Special Olympics Chapter program in

my state, or the athlete has had a full radiological examination, which establishes the absence of Atlanto-axial Instability. I am aware that if I choose not to

complete the “Special Release for Athletes with Atlanto-Axial Instability” form which establishes the absence of Atlanto-axial Instability, the athlete must have the

radiological examination before he/she can participate in judo, equestrian sports, gymnastics, diving, pentathlon, butterfly stroke, diving starts in swimming, high

jump, alpine skiing, snowboarding, squat lift and football team competition (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 and words in 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, on my behalf, 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.

By signing below, I am also permitting the Athlete to participate in the Special Olympics Healthy Athletes Program that provides individual screening

assessments of the health status and health care needs in the areas of: vision; oral health; hearing; podiatry; physical therapy; and a variety of health promotion

areas (height, weight, sun protection, etc.). I understand that participation in the healthy Athletes Program is voluntary and that I may decide that the Athlete will

not participate. I understand that provision of these health services is not intended as a substitute for regular health care and that the Athlete should seek his/her

own medical advice and assistance irrespective of the provision of these services. Neither Special Olympics Inc. nor Special Olympics Montana, through the

provision of these services are responsible for the Athlete’s health or health care.

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 above.

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

Revised 3/14/06