YOUNG ATHLETE INFORMATION

To be completed by the athlete or parent/guardian/caregiver

Name

First Name

Last Name

Date of Birth

YYYY

Gender

Phone

(###)

###

####

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Race/Ethnicity

Language(s) Spoken by Athlete

English

French

Spanish

American Sign Language (ASL)

Other

Legal Parent/Guardian Information

Does the athlete have a legal parent/guardain

Yes

EMERGENCY CONTACT

Someone other than parent/guardian previously listed

Name

First Name

Last Name

Phone

(###)

###

####

Relationship to athlete

ASSOCIATED CONDITIONS

Please Specify other known intellectual disability diagnoses:

ASSISTIVE DEVICES AND ACCOMMODATIONS

Do you use any of the following? Check all that apply

Mobility

Walker

Braces or crutches

Wheelchair

Removable orthotics

Prosthetics

None

Lifestyle Aids

CPAP

Dentures

Glasses, contact lenses, or protective eyewear

None

Communications

Hearing Aid

Communication devices

Sign Language

None

Medical Devices

Implantable cardioverter defibrillator (ICD)

Implantable device for seizure management

VP Shunt

Pacemaker

None

Do you have a specific dietary requirement?

If yes, please specify:

Do you use other assistive devices?

If yes, please specify:

GENERAL HEALTH QUESTIONS

Do you have a heart condition?

Do you have asthma?

Do you have diabetes that requires you to take insulin?

Do you have a vision impairment?

Do you have a hearing impairment?

Do you have a bleeding disorder?

Has a doctor ever limited your participation in sports?

Do you have epilepsy or any type of seizure disorder?

Do you have sickle cell disease?

Have you ever had a concussion?

If yes, please specify how many in your lifetime

If yes, date of last concussion

YYYY

Do you have behavioral, mental health, and/or sensory conditions

Yes

If yes, please specify:

Do you have severe allergies that requires the use of an EpiPen?

If yes, please specify if it is to any of the following:

Insect stings

Medication/drugs

Food

Latex

Other

If other, please specify:

Are you taking any prescription or over-the-counter medications or treatments? (Including birth control pills, insulin, multivitamins allergy shots or pills, EpiPen, asthma inhalers, epilepsy medication, anti-inflammatory medication, supplements of any kind. etc.)

Yes

If yes, please list:

Medication, Vitamin, or Supplement Name/Dosage/Times per day

Name of person completing the form

First Name

Last Name

Today's Date

YYYY

Is this form being completed by someone other than the athlete?

Relationship to athlete

SPECIAL OLYMPICS ENCOURAGES ALL PARTICIPANTS TO GET A YEARLY PHYSICAL EXAMINATION

WAIVERS, RELEASES, AND POLICIES

Please read the following information and check boxes fully before signing 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 mark one of these boxes:

(If either box is marked, an EMERGENCY MEDICAL CARE REFUSAL FORM must be completed.)

I have a religious or other objection to receiving medical treatment.

I do not consent to blood transfusions.

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: - 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.

Yes, I have read and understand the WAIVERS, RELEASES, AND POLICIES.

SYMPTOMS FOR SPINAL CORD COMPRESSION and ATLANTOAXIAL INSTABILITY (For athlete with Down syndrome only)

If I (or the athlete) have been diagnosed with or 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 – 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, the risk of illness (including communicable diseases), injury (including concussion), disability, 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. 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. 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. 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.

SPECIAL OLYMPICS IDAHO ATHLETE'S CODE OF CONDUCT

Special Olympics Idaho is committed to the highest ideals of sports and expects all athletes to honor sports and Special Olympics. All Special Olympics athletes and Unified Partners agree to the following code: I. SPORTSMANSHIP A. I will practice good sportsmanship. B. I will act in ways that bring respect to me, my coaches, my team and Special Olympics Idaho. C. I will not use bad language. D. I will not swear or insult other persons, this includes gossiping about other athletes or anyone involved with Special Olympics. E. I will not fight with other athletes, coaches, volunteers, or staff. II. TRAINING AND COMPETITION A. I will train regularly. B. I will learn and follow the rules of my sport. C. I will listen to my coaches and the officials and ask questions when I do not understand. D. I will always try my best during training, divisioning, and competitions. E. I will not “hold back” in preliminaries just to get into an easier final heat. III. RESPONSIBILITY FOR MY ACTIONS A. I will not make inappropriate or unwanted physical, verbal or sexual advances on others. B. I will not drink alcohol, smoke or take illegal drugs while representing Special Olympics at training sessions, competition or during Games. C. I will not take drugs for the purpose of improving my performance. D. I will obey all laws and Special Olympics rules. I understand that if I do not obey this Code of Conduct my Program or a Games Organizing Committee may not allow me to participate.

Yes, I have read and understand the WAIVER AND RELEASE OF LIABILITY / ASSUMPTION OF RISK / INDEMNIFICATION/ATHLETE'S CODE OF CONDUCT

Athlete Name

First Name

Last Name

ATHLETE SIGNATURE

(required for adult athlete with capacity to sign legal documents) I have read and understand this form. If I have questions, I will ask. By signing, I agree to this form.

Please type your FULL LEGAL NAME in the box below acknowledging you have read and understand all waivers and releases listed above and you agree to participate.

Date

YYYY

PARENT/GUARDIAN SIGNATURE

(required for athlete who is a minor or lacks capacity to sign legal documents) I am a parent or guardian of the athlete. I have read and understand this form and have explained the contents to the athlete as appropriate. By signing, I agree to this form on my own behalf and on behalf of the athlete.

Please type your FULL LEGAL NAME in the box below acknowledging you have read and understand all waivers and releases.

Date

YYYY

Relationship to athlete

EVALUATION AND RESEARCH (Optional)

Special Olympics wants to help our athletes and their families stay healthy and happy. We may take part in research studies and would share information for your potential participation. All studies will be checked by the Special Olympics Chief Health Officer. Would you or your family be interested in learning about research studies?

SPECIAL OLYMPICS FAMILY MEMBER CODE OF CONDUCT

We hope as family members, you will embrace the spirit of Special Olympics and help to provide a competition and training environment that enhances athlete character and skill development. The following Family Code of Conduct should be emphasized during training, competition, and special events at any level - including sub-Program, Accredited Program, National, Regional and World. As a Special Olympics family member, I pledge the following: •I will let my athlete choose the sports in which he/she would like to participate. •I will not force my choice upon him/her. •I will remember that athletes participate to have fun and that the game is for them; not for the family members. •I will see to it that my athlete's medical form is up-to-date, complete, and on file. •I will learn the rules of the game and the SOl policies before I complain or protest. •I (and my guests) will be a positive role model for my athlete and encourage sportsmanship by showing respect and courtesy, and by demonstrating positive support for al athletes, coaches, officials, and spectators at every game, practice, or competition. •I understand that I play a vital role in the health and safety of my athlete's participation. I have a responsibility to assist Special Olympics in providing for the health and safety of all athletes by reporting suspicious behavior, talking to my child about personal safety, dropping of and picking up my child/guard from Special Olympics events at the times designated by the organization (not excessively earlier or later than said established times), and any and all other reasonable measures to assist in the protection of Special Olympics athletes. •I (and my guests) will never engage in any kind of unsportsmanlike conduct, such as booing and taunting, refusing to shake hands, or using profane language and gestures with any official, coach, or family member. •I will never encourage any behaviors or practices that would endanger the health and well-being of the athletes. •I will teach my athlete to play by the rules and to resolve conflicts without resorting to hostility or violence. •I will demand that my athlete treat other athletes, coaches, officials, and spectators with respect, regardless of race, creed, color, sex, or ability. •I will teach my athlete that doing one's best is more important than winning, so that my athlete will never feel defeated by the outcome of a game or his/her performance. •I will praise my athlete for competing fairly and trying hard, and I will make my athlete feel like a winner every time. •I will never ridicule or yell at my athlete or other participants for making a mistake or losing a competition. •I will emphasize skill development and practices, and how they benefit my athlete over winning. I will also de-emphasize games and competition in lower age groups. •I will promote the emotional and physical well-being of the athletes ahead of any personal desire that I may have for my athlete to win. •I will respect the officials and their authority during games and competition, and will never question, discuss, or confront coaches during competitions. Instead, I will take time to speak with coaches at an agreed upon time and place. •I will demand a sports environment for my athlete that is free from drugs and alcohol, and I will refrain from their use at al sports events and competitions. •I will smoke/chew tobacco only in designated areas. •I will refrain from coaching my athlete or other athletes during competitions and practices if I am not the assigned coach. As a Special Olympics Accredited Program family member, I also understand that if I fail to abide by the aforementioned rules and guidelines, I may be subject to disciplinary action that could include, but may not be limited to, the following: • Verbal warning by officials, coaches, and/or sub-Program and Accredited Program personnel •Game suspension with written documentation of incident kept on file in the Accredited Program Office •Written warning •Game forfeit through official or coach •Season suspension •Misbehavior Report submitted to Event Director

Yes, I have read and understand the FAMILY CODE OF CONDUCT

SIGNATURE OF FAMILY MEMBER

Please type your FULL LEGAL NAME in the box below acknowledging you have reviewed , understand and agree to this Code of Conduct

Date

YYYY

YOUNG ATHLETE REGISTRATION FORM

Special Olympics Idaho

Hours

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