Athlete Registration

ATHLETE REGISTRATION

Required for all athletes participating in Special Olympics
Welcome to Special Olympics Connecticut Athlete Registration!

This form helps us gather the information we need to support each athlete’s safety, well-being, and participation.

Please answer each question as accurately as you can. The information you share will remain confidential and will only be used to ensure athletes have the best and safest experience possible.

This form is to be completed by the athlete or parent/guardian/caregiver/healthcare provider/group home or agency staff.

Contact Emily at emilyp@soct.org with any questions.
Is this form being completed by someone other than the Athlete?*

YesNo
Full name of person completing the form*
Relationship to the Athlete*
Athlete Information

To be completed by the athlete or parent/guardian/caregiver/healthcare provider/group home or agency staff
Athlete Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Date
Gender*
Athlete Email*
example@example.com
Type of Email*
Newsletter Opt-In

Yes! I’d like to receive emails from Special Olympics Connecticut with news, event updates, and ways to get involved. I understand I can unsubscribe at any time.
Preferred Phone Type*
Home Phone Number
Please enter a valid phone number.
Mobile Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Athlete Home Address (no P.O.Boxes)*
City*
State*
Zip Code*
Local Special Olympics Program*
Employer/School/Organization
Athlete's Capacity to Sign Documents*

I am under 18 years old and require my parent/guardian to sign on my behalfI am 18 years or older with capacity to sign documents on my own behalfI am 18 years or older without capacity to sign documents on my own behalf
Race/Ethnicity

American Indian/Alaskan NativeAsian AmericanBlack/African AmericanHispanic/LatinoMiddle Eastern/North AfricanMulti-RacialNative Hawaiian/Other Pacific IslanderWhite/CaucasianUnknownOtherPrefer not to answer
Race/Ethnicity: If Other, please describe
Languages

EnglishFrenchSpanishAmerican Sign Language (ASL)OtherNon-Verbal
Language: If Other, please list
Parent/Guardian Information
Parent/Guardian Full Name*
Parent/Guardian Email Address*
example@example.com
Parent/Guardian Relationship
Parent/Guardian Phone Type*

MobileLandline
Parent/Guardian Phone Number*
Please enter a valid phone number.
Parent/Guardian Address*
Emergency Contact Information
Emergency Contact Full Name*
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Relationship to Athlete*
Athlete Medical Information

Special Olympics encourages all participants to get a yearly physical examination.
Associated Conditions (select all that apply)*

AutismCerebral PalsyDown SyndromeFetal Alcohol SyndromeIntellectual DisabilityMarfan SyndromeSpina BifidaEpilepsyFragile X SyndromeUnknownOther
Please specify other known intellectual disability diagnoses/physical/behavioral disorders
Assistive Devices and Accommodations

Do you use any of the following? Select all that apply.
Mobility

WalkerProstheticsBraces or crutchesWheelchairRemovable orthotics
Lifestyle Aids

CPAPDenturesGlasses, contact lenses, or protective eyewear
Communications

Hearing AidCommunication devicesSign language
Medical Devices

Implantable Cardioverter Defibrillator (ICD)Implantable device for seizure managementVP shuntPacemaker
Do you use other assistive devices?

YesNo
If yes, please specify:
Do you have a specific dietary requirement?

YesNo
If yes, please specify:
General Health Questions
Do any of the following apply to you or your medical history? Select all that apply.

Heart conditionAsthmaDiabetes that requires you to take insulinVision impairmentHearing impairmentBleeding disorderEpilepsy or any type of seizure disorderSickle cell diseaseConcussionSevere allergies requiring the use of an EpiPenLimited participation in sports advised by a doctorOther behavioral, mental health, and/or sensory conditions that could impact your/other's participation
If yes to any of the above general health questions, please provide additional details:*
How many concussions have you had in your lifetime?*
Date of last concussion*

MonthDayYear
Date
Please specify if your allergies are to any of the following:*

Insect StingsMedication/drugsFoodLatexOther
For Other, please describe your allergies:*
Medications
Are you taking any prescription or over-the-counter medications or treatments? Including birth control pills, insulin, allergy shots or pills, EpiPen, asthma inhalers, epilepsy medication, anti-inflammatory medication, supplements of any kind.*

YesNo
Please list all medications, vitamins, and supplements:*
Emergency Medical Care Consent
Emergency Care Consent: 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 behalfI do not consent to emergency medical care on religious or other grounds
Emergency Medical Care Refusal

I do not consent to any kind of medical treatment, even in a life-threatening emergency.I do not consent to blood transfusions, even in a life-threatening emergency. I consent to all other kinds of emergency medical care.
I am the parent/guardian of the athlete and agree to the following:

1. No Consent to Emergency Medical Care. I understand that Special Olympics’ standard registration form requires athletes or their parents or guardians to consent to emergency medical care for the athlete if needed in an emergency.
Based on religious beliefs or other reasons I am not consenting to emergency medical care as follows.

2. Accompaniment of Athlete. I understand that I must be present in order to take personal responsibility for the athlete if any medical treatment is to be refused on the athlete’s behalf in a medical emergency arises. This includes
during meal times, in overnight accommodations, at training sessions and competitions, and during travel to and from Special Olympics activities.

3. Emergency Medical Care If Athlete Is Not Accompanied. I understand that, if I am not present and actively taking personal responsibility for the athlete during a medical emergency, Special Olympics may seek emergency medical
care for the athlete as recommended by medical professionals responding to the emergency.

4. Liability Release. On behalf of myself and the athlete, I release Special Olympics, its employees, and its volunteers from all claims that may arise out of taking or failing to take measures to provide the athlete with emergency medical
care. I am agreeing to this release because I have refused, knowingly and voluntarily, to give Special Olympics permission to take emergency measures, and I am expressly withholding consent to emergency medical care on religious or other grounds. For this form, “Special Olympics” means all Special Olympics organizations.
Parent/Guardian Signature for Emergency Medical Care Refusal*

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Parent/Guardian Signature Date for Emergency Medical Care Refusal*

MonthDayYear
Date
I am a Special Olympics athlete with capacity to sign documents on my own behalf and agree to the following:

1. No Consent to Emergency Medical Care. I understand that Special Olympics’ standard registration form requires athletes or their parents or guardians to consent to emergency medical care for the athlete if needed in an emergency.
Based on religious beliefs or other reasons I am not consenting to emergency medical care.

2. Printed Instructions. I agree to carry printed instructions that describe my religious or other objections to medical treatment and how I wish the person accompanying me to respond if I get sick or hurt and cannot speak for myself. I
agree to carry these printed instructions with me at all times during my participation in any Special Olympics activity, including during meal times, in overnight accommodations, at training sessions and competitions, and during travel to and from Special Olympics activities.

3. Friend or Family Accompaniment. I understand that I must be accompanied by an adult friend or family member in order for that person can take personal responsibility for me during a medical emergency where I am unable to speak for myself.
- Accompanying Adult Agreement. By signing, I agree to accompany the athlete during Special Olympics activities and take personal responsibility for the athlete during an emergency. I understand the extent to which the athlete does not consent to emergency medical care and agree to act in accordance with the athlete’s wishes as I understand them.
4. Emergency Medical Care. If Athlete Is Not Accompanied. I understand that, if I am not carrying the printed instructions or the accompanying adult is not present and actively taking personal responsibility for me during a medical emergency where I am unable to speak for myself, Special Olympics may seek emergency medical care for me as recommended by medical professionals responding to the emergency.

5. Liability Release. I release Special Olympics, its employees, and its volunteers from all claims that may arise out of taking or failing to take measures to provide me with emergency medical care. I am agreeing to this release because I have refused, knowingly and voluntarily, to give Special Olympics permission to take emergency measures, and I am expressly withholding consent to emergency medical care on religious or other grounds. For this form, “Special Olympics” means all Special Olympics organizations.
Athlete Signature for Emergency Medical Care Refusal*

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Athlete Signature Date for Emergency Medical Care Refusal*

MonthDayYear
Date
Signature of Accompanying Adult for Medical Care Refusal*

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Accompanying Adult Signature Date for Medical Care Refusal*

MonthDayYear
Date
Athlete Release

Please read the information contained here before signing the Athlete Release Waiver
I agree to the following:

1. Ability to Participate. I am physically able to take part in Special Olympics activities, and will abide by all applicable rules, requirements and codes of conduct.

2. Likeness Release. I give permission to Special Olympics, Inc., Special Olympics games organizing committees, Special Olympics accredited Programs (collectively “Special Olympics”), as well as official Special Olympics supporters and partners that have authorization from Special Olympics, to use my likeness, photo, video, name, voice, words, biographical information and similar or related material (my “likeness”) to promote Special Olympics and raise funds for Special Olympics. I understand that my likeness may be used in all forms of media in local or global campaigns – including those by supporters and partners of Special Olympics – but understand that my likeness will not be used to endorse commercial products or services. I understand that I will not be compensated for the use of my likeness.

3. 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 marked one of boxes above in the Emergency Care Consent section and completed the corresponding questions for Emergency Medical Care Refusal.

4. Overnight Stay. For some events, overnight accommodations may be required. If I have questions, I will contact my Special Olympics Program.

5. 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 have the right to decline Health programming treatment (which is different from sideline or
emergency medical care) at any time.”

6. 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 Connecticut:
- 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.
- Using my contact information for communicating with me about Special Olympics.
- Sharing my personal information confidentially with (i) researchers such as universities and public health agencies that are studying intellectual disabilities and the impact of Special Olympics activities, (ii) medical professionals in an emergency, and (i ii) government authorities for the purpose of assisting me with any visas required for international travel to Special Olympics events and for any other purpose necessary to protect public safety, respond to government requests, and report information as required by law.
- 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.
SYMPTOMS FOR SPINAL CORD COMPRESSION and ATLANTOAXIAL INSTABILITY (For athlete with Down syndrome only)
If I (or the athlete) (1) have been diagnosed with Atlantoaxial Instability, or (2) has experienced any of the following symptoms that have increased in severity over the past three years – difficulty controlling bowels or bladder; numbness or tingling in legs, arms, hands, or feet; weakness in arms, legs, hands or feet; burner/stinger/pinches nerve, pain in neck, back shoulders, arms, hands, buttocks, legs or feet; spasticity or paralysis, then I must obtain a review and permission from a licensed medical practitioner to train and/or participate in Special Olympics activities.

WAIVER AND RELEASE OF LIABILITY / ASSUMPTION OF RISK / INDEMNIFICATION
In consideration of being allowed to participate in any way in Special Olympics activities, the undersigned acknowledges, appreciates, and agrees that:

1. While particular rules and personal discipline may reduce this risk, participation in Special Olympics activities involve risks to the participant’s person including the risk of illness (including communicable diseases), bodily injury (including concussion), partial or total disability, paralysis, and death does exist.

2. If I observe any unusual or significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest Special Olympics representative immediately; and,

3. I understand the risks involved with participation in Special Olympics activities and/or related activities, including the risks, if any, arising from the conditions and use of the premises and on which any Special Olympics activity is occurring and/or any related premises. I fully accept and assume all risks and all responsibility for losses, costs, and damages I may incur as a result of my participation. To the fullest extent of the law, I release and agree not to sue any Special Olympics organization, its directors, agents, volunteers, and employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable owners and lessors of premises on which any Special Olympics activity is occurring (“Releasees”) related to any liabilities, claims, or losses on my account caused or alleged to be caused in whole or in part by the Releasees even if arising from the negligence of the Releasees including, but not limited to, the failure to perform maintenance, inspection, supervision or control of said premises and for the failure to warn of dangerous conditions existing at said premises, for negligent selection of certain Releasees or negligent supervision or instruction by certain Releasees.

4. I have read this release of liability and assumption of risk provision, fully understand its terms, acknowledge that I have given up substantial rights by signing it, and sign it freely and voluntarily without any inducement.

4.5 I further agree that if, despite this release, I, or anyone on my behalf, makes a claim against any of the Releasees, I will indemnify and hold harmless each of the Releasees from any such liabilities, claims, or losses as the result of such claim. I agree that if any part of this form is held to be invalid, the other parts shall continue in full force and effect.
Athlete Signature*

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Athlete Signature Date*

MonthDayYear
Date
Applicant Signature*

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Applicant Signature Date*

MonthDayYear
Date
Parent/Guardian Signature*

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Parent/Guardian Signature Date*

MonthDayYear
Date
ADMIN FIELDS
Form Submission Name
Email Opt-In

TrueFalse
Should be Empty:

ATHLETE REGISTRATION

Athlete Information

Parent/Guardian Information

Emergency Contact Information

Athlete Medical Information

Assistive Devices and Accommodations

General Health Questions

Medications

Emergency Medical Care Consent

Athlete Release

ADMIN FIELDS