APPLICATION FOR PARTICIPATION IN SPECIAL OLYMPICS GEORGIA

Valid Application for Participation is mandatory for all training and competitions
4000 Dekalb Technology Parkway Building 400, Suite 400 Atlanta, Georgia 30340 770-414-9390 Fax: 770-216-8339
Athlete Name
Area Agency
A
AB
New or Update
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SECTION A: ATHLETE HEALTH INFORMATION (SHOULD BE SUBMITTED EVERY 3 YEARS)
PARENT OR GUARDIAN AUTHORIZATION AND MEDIA RELEASE
On my own behalf or as the undersigned parent or legal guardian of the above named athlete, I hereby request permission for the athlete to participate in the Special Olympics Program.
I represent and warrant to you that the athlete is physically and mentally able to participate in Special Olympics, and I submit herewith a subscribed medical certificate.
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 a full radiological examination establishes the absence of Atlanto-axial Instability. I am aware that the sports and events for which the radiological examination is required are
equestrian sports, artistic gymnastics, diving, pentathlon, high jump, alpine skiing, soccer, butterfly stroke and diving starts in swimming. On behalf of the athlete and myself, I acknowledge that
the athlete will be using facilities at his/her own risk and I, on my own behalf, hereby release, discharge and indemnify Special Olympics from all liability for injury to person or damage to
property of myself and the athlete. In permitting the athlete to participate, I am granting permission to Special Olympics Georgia to use the name, likeness, voice and words of the athlete in
television, radio, films, newspapers, magazines, websites, and other media, and in any form not heretofore described, for the purpose of advertising or communicating the purpose and activities
of Special Olympics and in appealing for funds to support such activities.
If I am not personally present at Special Olympics activities in which the athlete is to compete, so as to be consulted in case of necessity, you are authorized on my behalf and at my account to take
such measures and arrange for such medical and hospital treatment as you may deem advisable for the health and well-being of the athlete. By signing this form I authorize Special Olympics
and/or its agents to make an independent investigation of my background, including those maintained by both public and private organizations and all public records. I understand that by
signing below I consent to participate in the Special Olympics Healthy Athletes program that provides individual screening assessments of health status and health care needs in the areas of:
vision; oral health possibly to include placement of sealants and fluoride varnish; hearing; physical therapy; and a variety of health promotion areas (height, weight, sun protection, etc.). I under-
stand there is no obligation to participate in the Healthy Athletes Program. I understand that when attending state events that there may be 2 or more people housed per room.
I, THE UNDERSIGNED ADULT ATHLETE, have read and fully understand the I, THE UNDERSIGNED PARENT OR GUARDIAN of the above specified athlete,
provisions of the above release and/or have had them explained. I hereby agree that I have read and fully understand the provisions of the above release and have explained
will be bound thereby and shall defend Special Olympics Georgia and hold it harmless them to said athlete. I hereby, agree that I and said minor will be bound thereby, and I
from disaffirmation thereof. I acknowledge and agree that the above information is shall defend Special Olympics Georgia and hold it harmless from disaffirmation thereof
accurate. by said minor. I acknowledge and agree that the above information is accurate.
Athlete Signature of Parent
and/or Legal Guardian
Witness Date Print Name Date
(Family member, coach, teacher, friend, other)
*A HEALTH SCREENING PERFORMED BYA LICENSED EXAMINER IS REQUIRED FOR INITIAL PARTICIPATION*
SOGA REV. 1-12-10 WHITE COPY - SOGA YELLOWCOPY - LOCAL COORDINATOR
MEDICAL CLEARANCE
PLEASE CHECK MEDICAL INFORMATION
Does the athlete have:
1. Heart Problems Yes No
2. Diabetes Yes No
3. Seizures/Epilepsy Yes No
4. Major Surgery/Serious Illness Yes No
5. Parent/Sibling (under 40)
died of heart disease Yes No
6. Down Syndrome Yes No
If athlete is Down Syndrome, have x-rays of
the C1-C2 vertebrae been taken and examined?
Yes No
Date of x-ray
Does the athlete have Atlanto-axial
Instability? Yes No
7. Vision Problems/Blind Yes No
8. Hearing Loss/Deaf Yes No
9. Does athlete use wheelchair? Yes No
Other
Current Medications Dosage
Allergies (Medication, Food, Insect Bites):
Date of Last Tetanus Shot:
*A HEALTH SCREENING BYA
LICENSED EXAMINER IS REQUIRED
EVERY 3 YEARS FOR ATHLETES
WITH YES CHECKED ON 1-5*
SECTION B
MEDICAL CERTIFICATION
I have examined the above named athlete and, in my
opinion, there is no mental or physical reason why he or
she should not participate in the Special Olympics sports
training and competition program. Further information
will be forwarded if required. Current medication, if any,
is specified with dosage on this application.
COMMENTS
Examination Date
Signature
Print Name
Address
City State Zip
Phone
Social Security Number (Athlete)
Athletes Name (last name, space, first name)
Agency Name
Athletes Mailing Address
Athletes City
State Zip Code Parents/Guardians Daytime Telephone
HEALTH INSURANCE & EMERGENCY INFORMATION
Medicaid Number Health Insurance Company Policy Number
Birthdate
M M D D Y Y Sex (M or F)
a a
a a
a a
a a
a a
a a
a a
a a
a a
a a
a a
Emergency Contact Phone ( )
Required for emergency purposes
Background (optional):
African American Caucasian Hispanic Native American
Other
Email
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Is the athlete employed? oYes oNo
If so, where?
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