Young Athletes Registration Form

Young Athlete Name*

First NameLast Name
Young Athlete Birth Date*

MonthDayYear
Gender:*

MaleFemale
Parent Contact Name*

First NameLast Name
Parent Contact Phone*
Parent Contact E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please click on your Area

22=Kcmetro Area33= St. Louis Metro Area44= Southwest Area66=Central Area77=Southeast Area88=North Area
Please choose one from the list*

Young Athlete with Intellectual DisabilityYoung Athlete without Intellectual Disability
Shirt Size*

Youth SmallYouth MedYouth LargeAdult SAdult M
What School or Daycare does athlete attend? *
Please remember to sign and date

Young Athletes Release Form – SUMMARY

1) PARAGRAPH ONE:

-Athlete gives consent to participate in Special Olympics Parent or guardian of a minor athlete gives permission for said minor to participate in Special Olympics

2) PARAGRAPH TWO:

-Notification of the right to use athlete’s likeness, voice or words for the purpose of Special Olympics publicity, and acknowledgement that data from the Pilot will be used for program evaluation and improvement

3) PARAGRAPH THREE:

-Authorization for Special Olympics to provide athlete with medical treatment in case of a medical emergency.

-Instructions for those with Religious Objections for emergency medical treatment: cross out Paragraph 5, initial the document and complete attached Religious Objections form on the back of this page

ANY CHANGES OR ADDITIONS TO THE FORM BELOW MUST BE APPROVED BY Special Olympics
Young Athletes Release Form TO BE COMPLETED BY PARENT OR GUARDIAN OF MINOR ATHLETE

I am the parent/guardian of Minor above :
The minor participant, on whose behalf I have complete the jot form application for participation in Special Olympics. The participant has my permission to participate in Special Olympics activities. I further represent and warrant that to the best of my knowledge and belief, the participant is physically and mentally able to participate in Special Olympics.
In permitting the participant to participate, I am specifically granting my permission, to Special Olympics to use the participant’s likeness, name, voice and words in television, radio, film, newspapers, magazines and other media, internet 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. I also understand that group data collected from the Young Athletes Pilot Program will be used to plan, evaluate, and improve the program.

If a medical emergency should arise during the participant’s participation in any Special Olympics activities, at a time when I am not personally present so as to be consulted regarding the participant’s care, I hereby authorize Special Olympics, on my behalf, to take whatever measures are necessary to ensure that the participant is provided with any emergency medical treatment, including hospitalization, which Special Olympics deems advisable in order to protect the participant’s health and well-being. (IF YOU HAVE RELIGIOUS OBJECTIONS TO RECEIVING SUCH MEDICAL TREATMENT, PLEASE CROSS OUT THIS PARAGRAPH, INITIAL IT AND SIGN AND ATTACH THE SPECIAL PROVISIONS REGARDING MEDICAL TREATMENT FORM)

I am the parent (guardian) of the participant named in this application. I have read and fully understand the provisions of the above release, and have explained these provisions to the participant. Through my signature on this release form, I am agreeing to the above provisions on my own behalf and on the behalf of the participant named above. I hereby give my permission for the participant named above to participate in Special Olympics games, recreation programs, and physical activity programs.
Religious Objections Form Special Olympics Provisions regarding Medical Treatment for Athletes having Religious Objections to Standard

YesNo
Signature
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