Health Messenger Information Form

By filling out and submitting this form, you are giving Special Olympics personal information that will help us find opportunities for you to be more active within Special Olympics and on behalf of people with intellectual disabilities. This personal information includes your name, image, telephone number, and other personally identifying and health related information.


We want you to understand some important points about how we will use and take care of your data:

-    By submitting this form, you give permission to Special Olympics, Inc., Special Olympics games organizing committees, and Special Olympics accredited Programs (collectively “Special Olympics”) to use your likeness, photo, video, name, voice, words, and biographical information to promote the work of Special Olympics and raise funds for Special Olympics.

-    Special Olympics may share your personal information with (i) medical professionals when necessary, and (ii) government authorities for any purpose necessary to protect public safety, respond to government requests, and report information as required by law.

-    Any use or sharing of your personal information will be consistent with the Special Olympics privacy policy, which you can read at www.SpecialOlympics.org/Privacy-Policy.


Special Olympics is a global organization with headquarters in the United States of America. By filling out and submitting this form, you accept that your personal information may be stored and processed somewhere outside the country where you live, including the United States. Such countries may not have the same level of personal data protection as the country where you live. You also recognize that the organization responsible for protecting your personal information under data protection laws is your local Special Olympics Program (contact info at www.SpecialOlympics.org/Programs).


Even though you are sharing personal information with Special Olympics, it is still yours. That means:

-    You have the right to ask to see your personal information or to know about the personal information that is processed about you.

-    You have the right to ask to correct, delete and restrict the processing of your personal information.

-    You also have a right to have your personal information sent to another organization on your request.

-    You have the right to file a complaint with a local data protection authority.

I consent that Special Olympics can use my information as stated in this document. Please tick.

1.    Please upload a document with your biography. Try to follow this pattern: https://www.dropbox.com/scl/fi/hjhh6i8w7zgcx8n5tblho/Health-Messenger-Bio-Guide.docx?dl=0&rlkey=25l4v1gp148wmhm5c8ajbf5yt 2.    Please upload a picture of yourself. The best kind of picture to upload is a headshot. A headshot is a picture that shows your face or your head and shoulders.

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Person Filling Out This Form

Health Messenger Information

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Please select the name of the state or country where your Special Olympic organization is registered.

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Please tell us the name of a city/town/village that you live in or that is closer to where you live.

Please tell us when did you become a Special Olympics athlete?

The best person to contact to connect with the Health Messenger.

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Best way to contact the Health Messenger.

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"Other" Contact Information

Mentor Information

Trainings

Please select the date the Health Messenger completed the training to become a Health Messenger.

The Health Messenger practicum is how Health Messengers put what they have learned into action. It's the health-focused project that Health Messengers commit to doing in their communities to demonstrate their leadership in health. Please tell us if you have completed a practicum.

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Please tell us more about your practicum session. Include information about the topic, the people you have reached, what lessons did you learn, and what were your challenges.

Please tell us the name of the training and the month and year as best as you can remember.

Additional Health Messenger Information

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Please check the sport or sports you participate in.

Unified activities*

Have you participated in unified activities?

Please list all the languages you are able to speak.

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Please select the diverse group you belong to.

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Health topics of interest are topics you are interested to learn and to educate others about in your role as a Health Messenger.

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A personal health story is a specific health experience you have had. Some examples are: a good or bad interaction you had with a health provider or a way you have improved your health.

Please tell us if you like speaking at public events like conferences and meetings.

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Please tell us if you like to speak to the media including radio, newspaper and television interviews.

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Please tell us if you are able to access reliable internet connection for online meetings and webinars.

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Please indicate if you want to continue as a Health Messenger.

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