Athlete Medical

PHYSICAL EXAM

ATHLETE INFORMATION

PARENT / GUARDIAN INFORMATION

(required if minor or otherwise has a legal guardian)

EMERGENCY CONTACT INFORMATION

PHYSICIAN & INSURANCE INFORMATION

ASSOCIATED CONDITIONS

ALLERGIES & DIETARY RESTRICTIONS

SPORTS PARTICIPATION

MENTAL HEALTH

MEDICATIONS

Please list any medications or supplements below

ATHLETE RELEASE FORM

I agree to the following:

1. Ability to Participate. I am physically able to take part in Special Olympics activities.
2. 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.
3. Emergency Care. If I am unable, or my guardian is unavailable, to consent or make medical decisions in an emergency,
4. Overnight Stay. I understand that Special Olympics has a housing policy.
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 can say no to treatment or anything else 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:
• 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 (iii) 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.

ATHLETE CODE OF CONDUCT

COMMUNICABLE DISEASES

ATHLETE LIKENESS RELEASE FOR SPONSORS (OPTIONAL)

Special Olympics relies on sponsors and partners to help support our mission. We often use photos, videos and stories of our athletes to show the impact of support by companies that sponsor Special Olympics. If you wish to allow your likeness to be used in this way, please read and sign below.

I agree to the following:

• I give permission to Special Olympics, Inc., Special Olympics games organizing committees, and Special
• Olympics accredited Programs (collectively “Special Olympics”) and their sponsors and partners to use my
• likeness, photo, video, name, voice, words, and biographical information (“my likeness”) to acknowledge the
• sponsors’ and partners’ support for Special Olympics.
• Special Olympics and its sponsors and partners will not use my Likeness to endorse commercial products or
• services.
• I understand I will not be compensated for the use of my Likeness.