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Special Olympics Colorado 12450 E Arapahoe Road, Suite C,
Centennial, CO 80112 Tel 720-359-3100 Tel 720-359-3136 Created by
the Joseph P. Kennedy Jr. Foundation for the benefit of persons
with intellectual disabilities Email
[email protected]
ATHLETE APPLICATION FOR PARTICIPATION
Last Name: First: Middle: ID#: Office Only
DOB: Gender: ☐ Female ☐ Male ☐ Transgender Wheelchair/Handicap
Accessibility: ☐Yes
Address: City: Zip:
Home Phone: Cell Phone: Work Phone:
Email: Athlete is his/her own guardian: ☐ Yes ☐ No
Ethnicity: ☐ White ☐ Black/African American ☐ Hispanic/Latino ☐
Asian ☐ Native American ☐ Middle Eastern ☐ Pacific Islander ☐
Caribbean Islander ☐ Other:
Team/Program: ☐School-Based ☐Community-Based
Coach:
Sports:
School District: School:
Employer: Position: Income: ☐$12,000↑
Living Situation: ☐ Independently in own apartment/home ☐ Host
Home or with a care provider ☐ Group Home/Residential Facility ☐
With parents/family How many people live in your house?
Household Income: ☐$0-$12,000 ☐$12,001-$16,000 ☐$16,001-$20,000
☐$20,001-$25,000 ☐$25,001-$30,000 ☐$30,001-$42,000 ☐$42,001-$99,999
☐+$100,000
Support Services: ☐ Medicaid ☐ Medicare ☐ SSI ☐ SNAP ☐ TANF ☐
CCCAP ☐ LEAP ☐ Food Assistance ☐ Other:
__________________________________________________________
PARENT/CAREGIVER #1: ☐ Parent ☐ Guardian ☐ Caregiver ☐
Other:
Last Name: First Name:
☐ Same Address as Athlete ☐ Same Phone Numbers as Athlete ☐ Same
Email as Athlete Address (if different from athlete): City: State:
Zip:
Home Phone: Cell Phone: Work Phone:
Email:
Employer: Position:
PARENT/CAREGIVER #2: ☐ Parent ☐ Guardian ☐ Caregiver ☐
Other:
Last Name: First Name:
☐ Same Address as Athlete/Caregiver 1 ☐ Same Phone #s as
Athlete/Caregiver 1 ☐ Same Email as Athlete/Caregiver 1
Address (if different from above): City: State: Zip:
Home Phone: Cell Phone: Work Phone:
Email:
Employer: Position:
EMERGENCY CONTACT: ☐ Parent/Caregiver #1 ☐ Parent/Caregiver #2 ☐
Other (Relationship):
Last Name: First Name:
Home Phone: Cell Phone: Work Phone:
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Special Olympics Colorado| Page 2| 5
ATHLETE APPLICATION FOR PARTICIPATION
Please submit form by: Email: [email protected]
Mail: 12450 E Arapahoe Road, Suite C, Centennial, CO 80112
Athlete Name: ID#: Office Only
RELEASE FORM
Physically & Mentally Able to Participate: I, the
undersigned, represent and warrant that, to the best of my
knowledge and belief, I am/my child/ward is physically and mentally
able to participate in Special Olympics. Special Olympics is
authorized to review the health information set forth in this
application and certify that there is no medical evidence that
would preclude me/my child/ward from participation. I understand
that if I/my child/ward has been diagnosed with Down Syndrome,
I/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 Atlantoaxial Instability. I
am aware that the sports requiring this radiological examination
are judo, equestrian sports, gymnastics, diving (including diving
starts), pentathlon, butterfly stroke, high jump, alpine skiing,
squat lifts, snowboarding, and soccer.
Initial
Media & Fundraising: Special Olympics has my permission to
use my/my child’s/ward’s likeness, voice and words in television,
radio, film, newspaper, magazines and any other media, and in any
form, for the purpose of promoting Special Olympics, announcing
honors & recognitions, and/or applying for funds to support
Special Olympics.
Initial
Emergency Care: If a medical emergency should arise during my/my
child’s/ward’s participation in any Special Olympics activities and
I am unable to give my consent, for whatever reason, I authorize
Special Olympics to take whatever measures are necessary and which
it deems advisable to protect my/my child’s/ward’s health and
wellbeing, including hospitalization. (If I refuse, the Emergency
Medical Care Refusal Form must be attached. Please call or email
for the Refusal Form. If Refusal Form is not attached, consent will
be considered granted. Refusal Form attached: ☐Yes ☐No)
Initial
Housing Policy: I acknowledge that Special Olympics events may
involve overnight activities and that housing arrangements for each
event may differ. I understand that I should contact my Regional
Manager if I have questions about housing arrangements for a
specific event or the housing policy in general.
Initial
Risk of Concussions & Injuries: I acknowledge that Special
Olympics requires coaches to pass an approved concussion awareness
and safety recognition program and I have read the policy as posted
on www.specialolympicsco.org. I understand that there is risk of
injury if I/my child/ward participate in Special Olympics and
additional health risks if I/my child/ward continues to play sports
after an injury. I understand that after an injury I/my child/ward
may have to get permission from a physician in order to resume
participation in Special Olympics.
Initial
Health Programs: If I/my child/ward take part in a Special
Olympics health programs, I consent to health activities,
screenings, and treatments. I understand that the health programs
do not replace my/my child’s/ward’s regular health care and I can
refuse/decline participation at any time.
Initial
Personal Information: I understand that my/my child’s/ward’s
information is confidential and will be used to: (1) ensure that I
am/my child/my ward is eligible to participate safely in Special
Olympics, (2) register me/my child/ward in trainings & events,
(3) share competition results and recognition, (4) provide health
information for health programs (if applicable), (5) provide
medical and contact information in an emergency, (6) respond to law
enforcement & emergency personnel to ensure public safety, and
(7) analyze aggregate data for continuous quality improvement and
funding needs. I understand that I can request to see and correct
my/my child’s/ward’s personal information.
Initial
I have read and fully understand the above provisions on this
release form and I have explained these provisions to my child/ward
as appropriate. I understand that through my signature on this
release form, I am agreeing to all of the above provisions on my
own behalf or the behalf of my child/ward, unless noted otherwise,
and hereby give my permission for me/my child/ward to participate
in Special Olympics games, recreation programs, and physical
activities.
Initial
Clearly Print Athlete’s Name:
Clearly Print Signer’s Name (unless same as above):
Signature: Date: ☐Adult Athlete/Self ☐Parent ☐Legal Guardian
☐Approved Staff ☐Other: ______________
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Special Olympics Colorado| Page 3| 5
ATHLETE APPLICATION FOR PARTICIPATION
Please submit form by: Email: [email protected]
Mail: 12450 E Arapahoe Road, Suite C, Centennial, CO 80112
Athlete Name: ID#: Office Only
HEALTH HISTORY: Athlete’s Diagnosis: ☐ Mild ☐ Moderate ☐
Profound/Pervasive
☐ Autism ☐ Cerebral Palsy ☐ Down Syndrome (Trisomy 21) ☐ Fetal
Alcohol Syndrome ☐ Fragile X Syndrome
☐ Intellectual/Cognitive Disabilities ☐ Traumatic Brain Injury ☐
Asperger’s ☐ Tourette’s ☐ Fetal Drug Exposure
☐ Developmental/Learning Delays ☐ Chromosomal Abnormality ☐
Microcephaly ☐ Hydrocephaly ☐ Shaken Baby
☐ Other:
Mental Health (Emotional/Psychiatric/Behavioral): ☐ Mild ☐
Moderate ☐ Profound/Pervasive
☐ Depression ☐ Bipolar ☐ Anxiety ☐ OCD ☐
Personality/Mood/Dissociative Disorder ☐ ADHD ☐ PTSD
☐ Impulse Control ☐ Schizophrenia/Delusional ☐ Other:
Loss of Consciousness/Fainting Yes No High Blood Pressure Yes
No
Enlarged Spleen Yes No High Cholesterol Yes No
Visual Impairment: ☐ Not Corrected ☐ Corrected Hearing
Impairment: ☐ Not Corrected ☐ Corrected
Blind Yes No Deaf Yes No
Single Kidney Yes No Strokes/Mini Strokes (TIA) Yes No
Sickle Cell Trait/Disease Yes No Concussions/Concussion Symptoms
Yes No
Easy Bleeding Yes No Asthma Yes No Urinary/Bowel Discomfort
& Incontinence Yes No Diabetes Yes No
Numbness & Tingling in Extremities Yes No Spina Bifida Yes
No
Weakness in Extremities Yes No Heat Stroke/Heat Illness Yes
No
Nerve Pain/Pinched Nerve Yes No Scoliosis Yes No
Head Tilt Yes No Tobacco Use Yes No
Spasticity Yes No Non-Verbal Yes No
Paralysis: Yes No Cancer: Yes No
Immunizations Up to Date (optional – attach Immunization
Record)
Yes No Other: Yes No
Date of Most Recent Tetanus Immunization:
Heart: ☐Irregular Heart Beat ☐Congenital Heart Defect ☐Heart
Attack ☐Cardiomyopathy ☐Heart Valve Disease ☐Heart Murmur
☐Endocarditis ☐Heart Disease ☐Abnormal EKG ☐Abnormal Echo
Explain:
During or After Exercise: ☐Dizziness ☐Headache ☐Chest Pain
☐Shortness of Breath ☐Extreme Exhaustion
Explain:
Bone/Joint Problems: ☐Osteoporosis ☐Osteopenia ☐Arthritis
☐Broken Bones ☐Dislocated Joints
Explain:
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Special Olympics Colorado| Page 4| 5
ATHLETE APPLICATION FOR PARTICIPATION
Please submit form by: Email: [email protected]
Mail: 12450 E Arapahoe Road, Suite C, Centennial, CO 80112
Athlete Name: ID#: Office Only
Serious Head Injury: Yes No Explain:
Major Surgeries: Yes No Explain:
Requires Extra Supervision: Yes No Explain:
Self-Injurious & Aggressive Behaviors: Yes No Explain:
Chronic & Acute Infections/Diseases: Yes No Explain:
Family member has died of heart problems and/or while
exercising: Yes No Explain:
Seizures/Epilepsy: Yes No Type: Frequency:
Assistive Devices: ☐Brace ☐Colostomy ☐Communication Device
☐C-PAP Machine ☐Crutches
☐Walker ☐Dentures ☐Glasses ☐Contacts
☐G-Tube/J-Tube ☐Hearing Aid ☐Implanted Devices
☐Inhaler ☐Pacemaker ☐Removable Prosthetics
☐Splint ☐Wheelchair ☐Cane ☐Other:
_______________________________________
Allergies: ☐No Known Allergies ☐Seasonal ☐Latex Medications:
Insect Bites & Stings:
Food:
Special Diet:
Health Insurance: Policy Number:
Primary Care Physician: Phone Number:
Doctor’s Office/Practice:
Athlete consents to Emergency Medical Care: (If left blank,
medical consent will be considered granted)
Yes No Emergency Care Refusal Form is attached. (Contact
720-359-3100 or email below for Refusal Form. If form is not
attached, consent will be considered granted)
Yes No
MEDICATIONS: Please list medications and/or attach a medication
list. Medication List Attached: Yes No Does the athlete take any
medications that the coach needs to be aware of? Yes No
Explain:
Mediation/OTC/Vitamin/Supplement Dosage X/Day
Mediation/OTC/Vitamin/Supplement Dosage X/Day
Number of years the athlete has participated in Special
Olympics: ☐0 (New) ☐0-3 ☐3-6 ☐6-9 ☐9-12 ☐12+
Preferred Point of Contact: ☐Athlete/Me ☐Parent/Caregiver 1
☐Parent/Caregiver2 ☐Emergency Contact
Preferred Method of Contact for Non-Emergencies: (Please ensure
you provided the appropriate contact information on page 1.)
☐Email ☐Cell ☐Text ☐Home Phone ☐Work Phone
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Special Olympics Colorado| Page 5| 5
ATHLETE APPLICATION FOR PARTICIPATION
Please submit form by: Email: [email protected]
Mail: 12450 E Arapahoe Road, Suite C, Centennial, CO 80112
Athlete Name: ID#: Office Only
Patient Last Name: First: DOB:
PHYSICAL EXAMINATION: Must be filled out by a: ☐MD ☐PA ☐NP ☐DO
☐Other: ___________________ (This form cannot be filled out by a
chiropractor).
I have attached one of the following acceptable substitutes for
this form: ☐Yes ☐No ☐ (School) Sports Physical ☐ Annual Physical
Exam with Physician Statement of Consent for Participation
(Physician must clearly state that the athlete is “cleared/able”
to participate in Special Olympics/sports/recreational
activities).
Height: Weight: BMI: Body Fat%: Pulse: O2Sat: BP:
Vision = 20/40 or better ☐Yes (L/R) ☐No (L/R) ☐NA Bowel Sounds
☐Yes ☐No Hearing (Response) ☐Yes (L/R) ☐No (L/R) ☐NA Hepatomegaly
☐Yes ☐No
Ear Canal ☐Clear (L/R) ☐Cerumen (L/R) ☐Foreign Body (L/R)
Splenomegaly ☐Yes ☐No Tympanic Membrane ☐Clear (L/R) ☐Perforation
(L/R) ☐Infection (L/R)
Abdominal Tenderness ☐No ☐RUQ ☐RLQ ☐LUQ ☐LLQ
Oral Hygiene ☐Good ☐Fair ☐Poor Kidney Tenderness ☐No ☐Right
☐Left
Heart Murmur (Supine(S) & Upright (U))
☐No (S/U) ☐1/6 -2/6 (S/U) ☐3/6↑ (S/U) Extremity Reflexes (Upper
(U) & Lower (L))
☐Normal (U/L & R/L)
☐Diminished (U/L & R/L)
☐Hyperreflexia (U/L & R/L)
Lymph Nodes ☐Normal ☐Abnormal Thyroid ☐Normal ☐Abnormal
Heart Rhythm ☐Regular ☐Irregular Spasticity ☐No ☐Yes
Lungs ☐Clear ☐Not Clear Tremor ☐No ☐Yes
Cyanosis ☐No ☐Yes Loss of Sensitivity ☐No ☐Yes
Leg Edema ☐No (L/R) ☐1+ ☐2+ ☐3+ ☐4+ (L/R) Neck & Back
Mobility ☐Full ☐Not Full
Radial Pulse Symmetry ☐Yes ☐R>L ☐L>R Extremity Mobility
☐Full (U/L) ☐Not Full (U/L)
Clubbing ☐No ☐Yes Extremity Strength ☐Full (U/L) ☐Not Full
(U/L)
Abnormal Gait ☐No ☐Yes Other:
ATLANTOAXIAL INSTABILITY (AAI) ☐ Athlete shows NO EVIDENCE of
neurological systems or physical findings associated with spinal
cord compression or Atlantoaxial Instability.
☐ Athlete has neurological systems or physical findings that
could be associated with spinal cord compression or Atlantoaxial
Instability and must receive an additional neurological evaluation
to rule out additional risk of spinal cord injury prior to
clearance for sports participation. (Please call or email for the
Atlantoaxial Instability Special Release Form to take to your
neurological evaluation).
MEDICAL PROFESSIONAL’S RECOMMENDATION ☐ This athlete IS ABLE to
participate in Special Olympics sports without
restrictions/limitations.
☐ This athlete is able to participate in Special Olympics sports
WITH RESTRICTIONS/LIMITATIONS.
RESTRICTIONS/LIMITATIONS: ☐ This athlete MAY NOT PARTICIPATE in
Special Olympics sports, at this time, and must be further
evaluated by a physician. Please call or email for the Special
Olympics Further Medical Examination Form to take to your next
examination for the following concerns: ☐Cardiac ☐Acute Infection
☐O2 Saturation < 90% on Room Air ☐Neurology ☐Stage II
Hypertension or Greater ☐Hepatomegaly/Splenomegaly ☐Other:
____________________________________
Referrals: ☐Cardiologist ☐Neurologist ☐Primary Care Physician
☐Vision Specialist ☐Hearing Specialist ☐Dentist/Dental Hygienist
☐Podiatrist ☐Physical Therapist ☐Nutritionist ☐Other/Notes:
_____________________________________________________________________
Name: License:
Email: Phone:
Address/Stamp:
Licensed Medical Professional’s Signature Date of Exam
