Fillable ATHLETE REGISTRATION Registration Forms Instructional Cover Letter Welcome

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ATHLETE REGISTRATION Registration Forms Instructional Cover Letter Welcome

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ATHLETE REGISTRATION
Registration Forms Instructional Cover Letter
Dear Special Olympics Washington Athlete:
Welcome to Special Olympics Washington! Through the power of sports, our participants find
joy, confidence and fulfillment — on the playing field and in life. Whether you are new to
Special Olympics Washington or have been involved for years, we are excited you are part of
the movement!
To register or re-register as a Special Olympics athlete, please complete the enclosed forms
and provide them to your coach. All forms are required to participate:
REGISTRATION FORM (page 1): This form asks for contact and other important information
related to the athlete. If you do not yet have a team, please indicate that you need one in the
‘Program-Team’ line on the registration form.
MEDICAL FORM (page 2-4): This form is designed to identify health concerns that are more
common among people with intellectual disabilities and clear an athlete to participate. Please
fill out the Health History section on pages 1 and 2. If you do not understand any parts of the
form, you may leave those parts blank to be discussed during the exam. The Physical Exam
section on page 3 should be filled out and signed by a licensed medical professional (for
example, Physician, Registered Nurse Practitioner, or Physician Assistant).
RELEASE FORM (page 5): This form goes over some important details about Special Olympics
Washington participation.
If participation is denied by the primary care physician and additional examination is needed to
be cleared. Please visit our athlete registration page (sowa.org/athlete-registration/) under the
supplemental forms section to download and print the ‘Medical Referral Form’. This form will
need to be signed by the specialist and returned with paperwork above to participate. If this
applies to you or if you have any other questions, please use the contact below.
If you have any additional questions or need clarification on any of the items on the forms,
please contact us: participation@sowa.org
We are looking forward to seeing you out on the field!
-Your Special Olympics Washington Staff and Community
A1 Athlete Registration – updated 2020/2021
ATHLETE REGISTRATION FORM
ATHLETE INFORMATION
First Name:
Middle Name:
Last Name:
Preferred Name:
Date of Birth (mm/dd/yyyy):
Female Male
Race/Ethnicity (optional):
American Indian/Alaskan Native
Black or African American
White/Caucasian
Asian American
Native Hawaiian/Pacific Islander
Hispanic or Latinx
Language(s) Spoken in Athlete’s Home: (Check all that apply)
English
Spanish
Other (please list):
Street Address:
City:
Zip Code:
Phone:
E-mail:
Sports/Activities:
Athlete Employer, if any (Optional):
Does the athlete have the capacity to consent to medical treatment on his or her own behalf? Yes No
PARENT / GUARDIAN INFORMATION (required if minor or otherwise has a legal guardian)
Name:
Relationship:
Same Contact Info as Athlete
Street Address:
City:
Zip Code:
Phone:
E-mail:
EMERGENCY CONTACT INFORMATION
Same as Parent/Guardian
Name:
Phone:
Relationship:
PHYSICIAN & INSURANCE INFORMATION
Physician Name:
Physician Phone:
Insurance Company:
Insurance Policy Number:
Insurance Group Number:
State Special Olympics Program:_____________________________ Local Area/Delegation:______________________
Are you a new athlete to Special Olympics or Re-Registering?
New Athlete
Re-Registering
Gender Identity:
Prefer:
___________
Two/More Races
Please list other:
Medical Form for US Programs – updated 2020/2021 Special Olympics Medical Form | 1 of 4
Athlete Medical Form – HEALTH HISTORY
(To be completed by the athlete or parent/guardian/caregiver and brought to exam)
ASSOCIATED CONDITIONS - Does the athlete have (check any that apply):
Autism Down Syndrome Fragile X Syndrome
Cerebral Palsy Fetal Alcohol Syndrome
Other Syndrome, please specify:_______________________________________________________________________________
ALLERGIES & DIETARY RESTRICTIONS
ASSIST,9( DEVICES - Does the athlete use (check any that apply):
No Known Allergies Brace Colostomy Communication Device
Latex C-PAP Machine Crutches or Walker Dentures
Medications:_______________________________
Glasses or Contacts G-Tube or J-Tube Hearing Aid
Insect Bites or Stings:_______________________
Implanted Device Inhaler Pacemaker
Food:____________________________________
Removable Prosthetics Splint Wheel Chair
List any special dietary needs:
SPORTS PARTICIPATION
List all Special Olympics sports the athlete wishes to play:
Has a doctor ever limited the athlete’s participation in sports?
No Yes If yes, please describe:
SURGERIES, INFECTIONS, VACCINES
List all past surgeries:
Does the athlete currently have any chronic or acute infection?
No Yes If yes, please describe:
Has the athlete ever had an abnormal Electrocardiogram (EKG) or Echocardiogram (Echo)? If yes, describe date and results
Yes, had abnormal EKG
Yes, had abnormal Echo
Has the athlete had a Tetanus vaccine in the past 7 years? No Yes
FAMILY HISTORY
Has any relative died of a heart problem before age 50?
No Yes
Has any family member or relative died while exercising?
No Yes
List all medical conditions
that run in the athlete’s family:
Athlete First & Last Name:________________________________________ Preferred Name:_________________________
Athlete Date of Birth (mm/dd/yyyy):__________________________________________
Female Male
STATE PROGRAM:________________________________ E-mail:____________________________________________________
EPILEPSY AND/OR SEIZURE HISTORY
Epilepsy or any type of seizure disorder
No Yes
If yes, list seizure type:______________________________________________________________________________________
If yes, had seizure during the past year?
No Yes
MENTAL HEALTH
Self-injurious behavior during the past year
No Yes
Depression (diagnosed)
No Yes
Aggressive behavior during the past year
No Yes
Anxiety (diagnosed)
No Yes
Describe any additional
mental health concerns:
Other Prefer
Medical Form for US Programs – updated 2020/2021 Special Olympics Medical Form |
2 of 4
Athlete Medical Form – HEALTH HISTORY
(To be completed by the athlete or parent/guardian/caregiver and brought to Exam)
HAS THE ATHLETE EVER BEEN DIAGNOSED WITH OR EXPERIENCED ANY OF THE FOLLOWING CONDITIONS
Loss of Consciousness
No
Yes
High Blood Pressure
No
Yes
Stroke/TIA
No
Yes
Dizziness during or after exercise
No
Yes
High Cholesterol
No
Yes
Concussions
No
Yes
Headache during or after exercise
No
Yes
Vision Impairment
No
Yes
Asthma
No
Yes
Chest pain during or after exercise
No
Yes
Hearing Impairment
No
Yes
Diabetes
No
Yes
Shortness of breath during or after exercise
No
Yes
Enlarged Spleen
No
Yes
Hepatitis
No
Yes
Irregular, racing or skipped heart beats
No
Yes
Single Kidney
No
Yes
Urinary Discomfort
No
Yes
Congenital Heart Defect
No
Yes
Osteoporosis
No
Yes
Spina Bifida
No
Yes
Heart Attack
No
Yes
Osteopenia
No
Yes
Arthritis
No
Yes
Cardiomyopathy
No
Yes
Sickle Cell Disease
No
Yes
Heat Illness
No
Yes
Heart Valve Disease
No
Yes
Sickle Cell Trait
No
Yes
Broken Bones
No
Yes
Heart Murmur
No
Yes
Easy Bleeding
No
Yes
Dislocated Joints
No
Yes
Endocarditis
No
Yes
If female athlete, list date of last menstrual period:____________________
Describe any past broken bones or dislocated joints
(if yes is checked for either of those fields above):
List any other ongoing or past medical conditions:
Neurological Symptoms for Spinal Cord Compression and Atlanto-axial Instability
Difficulty controlling bowels or bladder
No
Yes
If yes, is this new or worse in the past 3 years?
No
Yes
Numbness or tingling in legs, arms, hands or feet
No
Yes
If yes, is this new or worse in the past 3 years?
No
Yes
Weakness in legs, arms, hands or feet
No
Yes
If yes, is this new or worse in the past 3 years?
No
Yes
Burner, stinger, pinched nerve or pain in the neck, back,
shoulders, arms, hands, buttocks, legs or feet
No
Yes
If yes, is this new or worse in the past 3 years?
No
Yes
Head Tilt
No
Yes
If yes, is this new or worse in the past 3 years?
No
Yes
Spasticity
No
Yes
If yes, is this new or worse in the past 3 years?
No
Yes
Paralysis
No
Yes
If yes, is this new or worse in the past 3 years?
No
Yes
PLEASE LIST ANY MEDICATION, VITAMINS OR DIETARY SUPPLEMENTS BELOW
(includes inhalers, birth control or hormone therapy)
Medication, Vitamin or
Supplement Name
Dosage
Times
per Day
Medication, Vitamin or
Supplement Name
Dosage
Times per
Day
Medication, Vitamin or
Supplement Name
Dosage
Times
per Day
Is the athlete able to administer his or her own medications? No Yes
Name of Person Completing this Form
Relationship to Athlete Phone Email
Athlete’s First and Last Name:_______________________________________________________
Medical Form for US Programs – updated 2020/2021 Special Olympics Medical Form |
3 of 4
Athlete Medical Form – PHYSICAL EXAM
(To be completed by a Licensed Medical Professional qualified to conduct exams & prescribe medications)
MEDICAL PHYSICAL INFORMATION
(To be completed by a Licensed Medical Professional qualified to conduct physical exams and prescribe medications)
Height
Weight
BMI (optional)
Temperature
Pulse
O
2
Sat
Blood Pressure (in mmHg)
Vision
cm
kg
BMI
C
BP Right:
BP Left:
Right Vision
20/40 or better No Yes N/A
in
lbs
Body Fat %
F
Left Vision
20/40 or better No Yes N/A
Right Hearing (Finger Rub) Responds No Response Can’t Evaluate
Left Hearing (Finger Rub) Responds No Response Can’t Evaluate
Right Ear Canal Clear Cerumen Foreign Body
Left Ear Canal Clear Cerumen Foreign Body
Right Tympanic Membrane Clear Perforation Infection NA
Left Tympanic Membrane Clear Perforation Infection NA
Oral Hygiene Good Fair Poor
Thyroid Enlargement No Yes
Lymph Node Enlargement No Yes
Heart Murmur (supine) No 1/6 or 2/6 3/6 or greater
Heart Murmur (upright) No 1/6 or 2/6 3/6 or greater
Heart Rhythm Regular Irregular
Lungs Clear Not clear
Right Leg Edema No 1+ 2+ 3+ 4+
Left Leg Edema No 1+ 2+ 3+ 4+
Radial Pulse Symmetry Yes R>L L>R
Cyanosis No Yes, describe
Clubbing No Yes, describe
Bowel Sounds Yes No
Hepatomegaly No Yes
Splenomegaly No Yes
Abdominal Tenderness No RUQ RLQ LUQ LLQ
Kidney Tenderness No Right Left
Right upper extremity reflex Normal Diminished Hyperreflexia
Left upper extremity reflex Normal Diminished Hyperreflexia
Right lower extremity reflex Normal Diminished Hyperreflexia
Left lower extremity reflex Normal Diminished Hyperreflexia
Abnormal Gait No Yes, describe below
Spasticity No Yes, describe below
Tremor No Yes, describe below
Neck & Back Mobility Full Not full, describe below
Upper Extremity Mobility Full Not full, describe below
Lower Extremity Mobility Full Not full, describe below
Upper Extremity Strength Full Not full, describe below
Lower Extremity Strength Full Not full, describe below
Loss of Sensitivity No Yes, describe below
SPINAL CORD COMPRESSION & ATLANTO-AXIAL INSTABILITY (AAI) (Select one)
Athlete shows NO EVIDENCE of neurological symptoms or physical findings associated with spinal cord compression or atlanto-axial instability.
OR
Athlete has neurological symptoms or physical findings that could be associated with spinal cord compression or atlanto-axial instability and
must receive an additional neurological evaluation to rule out additional risk of spinal cord injury prior to clearance for sports participation.
ATHLETE CLEARANCE TO PARTICIPATE (TO BE COMPLETED BY EXAMINER ONLY)
Licensed Medical Examiners: It is recommended that the examiner review items on the medical history with the athlete or their guardian, prior to
performing the physical exam. If an athlete needs further medical evaluation please have specialist complete referral linked here and return SOWA.
This athlete is ABLE to participate in Special Olympics sports without restrictions.
This athlete is ABLE to participate in Special Olympics sports WITH restrictions. Describe ___________________________________________
This athlete MAY NOT participate in Special Olympics sports at this time & MUST be further evaluated by a physician for the following concerns:
Concerning Cardiac Exam
Acute Infection
O
2
Saturation Less than 90% on Room Air
Concerning Neurological Exam
Stage II Hypertension or Greater
Hepatomegaly or Splenomegaly
Other, please describe:
Additional Licensed Examiner’s Notes and Recommended (but not required) Follow-up:
Follow up with a cardiologist
Follow up with a neurologist
Follow up with a primary care physician
Follow up with a vision specialist
Follow up with a hearing specialist
Follow up with a dentist or dental hygienist
Follow up with a podiatrist
Follow up with a physical therapist
Follow up with a nutritionist
Other/Exam Notes:
Name:
E-mail:
Signature of Licensed Medical Examiner Exam Date
Phone: License #:
Athlete’s First and Last Name:_______________________________________________
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A1 Athlete Registration – Updated 2020/2021
ATHLETE RELEASE FORM
I agree to the following:
1. Ability to Participate. I give permission to Special Olympics, Inc., Special Olympics games organizing committees,
and Special Olympics accredited Programs (collectively “Special Olympics”) to use my likeness, photo, video, name,
voice, words, and biographical information to promote Special Olympics and raise funds for Special Olympics.
2. Likeness Release. I give permission to Special Olympics Washington to use my likeness, photo, video, name, voice,
words, and biographical information to promote the program.
3. Risk of Concussion and Other Injury. I know there is a risk of injury. I understand the risk of continuing to play sports
with or after a concussion or other injury. I may have to get medical care if I have a suspected concussion or other injury.
I also may have to wait 7 days or more and get permission from a doctor before I start playing sports again.
4. Emergency Care. If I am unable, or my guardian is unavailable, to consent or make medical decisions in an emergency,
I authorize Special Olympics to seek medical care on my behalf, unless I mark one of these boxes:
5. Overnight Stay. For some events, I may stay in a hotel or someone’s home. If I have questions, I will ask.
6. Health Programs. If I take part in a health program, I consent to health activities, screenings, and treatment. This
should not replace regular health care. I can say no to treatment or anything else at any time.
7. Personal Information. I understand that Special Olympics will be collecting my personal information as part of my
participation, including my name, image, address, telephone number, health information, and other personally identifying
and health related information I provide to Special Olympics (“personal information”).
• I agree and consent to Special Olympics:
o using my personal information in order to: make sure I am eligible and can participate safely; run trainings and
events; share competition results (including on the Web and in news media); provide health treatment if I participate
in a health program; analyze data for the purposes of improving programming and identifying and responding to
the needs of Special Olympics participants; perform computer operations, quality assurance, testing, and other
related activities; and provide event-related services.
o using my contact information for communicating with me about Special Olympics.
• I have the right to ask to see my personal information or to be informed about the personal information that is processed
about me. I have the right to ask to correct and delete my personal information, and to restrict the processing of my
personal information if it is inconsistent with this consent.
• Privacy Policy. Personal information may be used and shared consistent with this form and as further explained in the
Special Olympics privacy policy at www.SpecialOlympics.org/Privacy-Policy.
8. Optional Informational Responses.
• Please list your current living/housing situation (group home, with family, etc.):____________________________
• How did you hear about us:____________________________
Athlete Name:
ATHLETE SIGNATURE (required for adult athlete with capacity to sign legal documents)
I have read and understand this form. If I have questions, I will ask. By signing, I agree to this form.
Athlete Signature:
Date:
PARENT/GUARDIAN SIGNATURE (required for athlete who is a minor or lacks capacity to sign legal documents)
I am a parent or guardian of the athlete. I have read and understand this form and have explained the contents
to the athlete as appropriate. By signing, I agree to this form on my own behalf and on behalf of the athlete.
Parent/Guardian Signature:
Date:
Printed Name:
Relationship:
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ATHLETE REGISTRATION Registration Forms Instructional Cover Letter Welcome

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Completed 3 July 2021

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