Special Olympics Medical Form (Page 3 of 3) in pdf

Athlete’s Name:

SPECIAL OLYMPICS KENTUCKY OFFICIAL RELEASE

TO BE COMPLETED BY PARENT/GUARDIAN OF MINOR ATHLETE OR

ADULT ATHLETE 18 YEARS OR OLDER

I am the parent/guardian or at least 18 years old and my own guardian and have submitted the attached application for

participation in Special Olympics. Permission has been given for the listed person 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 medical professional 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 licensed medical professional has

detected symptoms that might result from spinal cord compression, including Atlanto-axial Instability, then the Athlete will

only be permitted to participate in Special Olympics sports training and competition if the Athlete has a thorough

neurological evaluation from a physician who certifies that the Athlete may participate and I have signed a consent

acknowledging that I have been informed of the findings of the physician.

In permitting the Athlete to participate, I am specifically granting my permission, forever, 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 publicizing, promoting or communicating the purposes and activities of Special Olympics and/or applying

for funds to support those purposes and activities.

By signing below, I am also permitting the Athlete to participate in the Special Olympics Healthy Athletes Program, which

provides individual screening assessments of health status and health care needs in the areas of: vision; oral health; hearing;

physical therapy; and a variety of health promotion areas (height, weight, sun protection, etc.). I understand that

information gathered as part of the Healthy Athletes Program screening process may be used in group form (anonymously)

to assess and communicate the overall health needs of athletes and to develop programs to address those needs. I

understand that notwithstanding my consent, there is no obligation for the Athlete to participate in the Healthy Athletes

Program 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 care. I also understand that the Athlete should seek his/her own medical advice and

assistance irrespective of the provision of these services and that Special Olympics through the provision of these services is

not making itself responsible for athlete’s health.

I acknowledge that Special Olympics events may involve overnight activities and that the housing arrangements for

each event may differ. I understand that I should contact the Special Olympics Program in my jurisdiction if I have any

questions about housing arrangements for a specific event or the housing policy in general.

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, that Special Olympics deems advisable in order to protect the Athlete’s health and well-being. IF

YOU HAVE RELIGIOUS OBJECTIONS TO RECEIVING SUCH MEDICAL TREATMENT, PLEASE CROSS OUT THIS

PARAGRAPH AND INITIAL IT.

I am the parent (guardian) of the Athlete named in this application or at least 18 years old and my own guardian. 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 or myself to participate in Special Olympics games, recreation

programs, and physical activity programs.

_____________________________________________________________________

_____________________________

Signature of Parent/Guardian/Adult Athlete (if own legal guardian)

Date

OVER

Special Olympics Kentucky NEW Medical Form - Updated June 2015 | 3

Special Olympics Medical Form Page 3

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