SONorCal Athlete Application This form is required to participate as an athlete. If you have questions, please visit our FAQ. Athlete Information First Name Last Name Preferred name: If different than First Name Date of Birth MM/DD/YYYY Phone 10 digit phone. Numbers only Email Address City StatePlease select... AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code 5 digit zipcode County Participating in Are you, the applicant, an Adult (18+) with the capacity to legally sign documents? If so, please select "yes." If you are an individual completing this form on behalf of the applicant, please select "no."YesNo Do/Did you participate in Special Olympics at your school (Unified Sports)?YesNo If Yes, which school(s)? Gender / Race / Language Gender Race/Ethnicity Languages SpokenCheck all that apply Please select... English Spanish Arabic ASL Cantonese Farsi Japanese Korean Mandarin Punjabi Russian Tagalog Vietnamese OtherHold Ctrl to select Other Languages Parent/Guardian Name of Group Home (if applicable) First Name Last Name Phone 10 digit phone. Numbers only Email Date of Birth MM/DD/YYYY Address City StatePlease select... AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code 5 digit zipcode Relationship to Athlete I am the Emergency contact Emergency Contact - *please enter name of another individual who can be contacted in an emergency* First and Last Name Emergency contact must be someone besides the athlete Phone Enter 10 digit phone. Numbers only Relationship to Athlete Athlete Health Information Associated Conditions (check all that apply) *REQUIRED* AutismYesNo Cerebral PalsyYesNo Down SyndromeYesNo Marfan SyndromeYesNo Spina BifidaYesNo Fetal Alcohol SyndromeYesNo Fragile X SyndromeYesNo Please specify other known intellectual disability diagnoses: Assistive Devices and Accommodations *REQUIRED* Please note any devices used WalkerYesNo Braces or CrutchesYesNo WheelchairYesNo ProstheticsYesNo Removable OrthodonticsYesNo Please list any additional assistive devices: Lifestyle Aids Glasses, contact lenses, or protective eyewearYesNo CPAPYesNo DenturesYesNo Communications Hearing AidYesNo Sign LanguageYesNo Communication DevicesYesNo Medical Devices Implantable device for seizure managementYesNo VP ShuntYesNo PacemakerYesNo Implantable cardioverter defibrillator (ICD)YesNo Dietary Requirements Do you have a specific dietary requirement?YesNo If Yes, please specify General Health Questions Do you have a heart condition?YesNo Do you have Asthma?YesNo Do you have Diabetes that requires taking insulin?YesNo Do you have a vision impairment?YesNo Do you have a hearing impairment?YesNo Do you have a bleeding disorder?YesNo Has a Doctor ever limited your participation in sports?YesNo Do you have epilepsy or any type of seizure disorder?YesNo Do you have Sickle Cell Disease?YesNo Do you have another medical condition not listed?YesNo If answered "yes" to any of the above questions, please provide details here: Have you ever had a concussion?YesNo If Yes, please specify how many in your lifetime: Date of last one: MM/DD/YYYY Do you have behavioral, mental health, and/or sensory conditions?YesNo If Yes, please specify: Do you have severe allergies that requires the use of an EpiPen?YesNo If yes, please specify below Insect stingsYesNo Medication/DrugsYesNo FoodYesNo LatexYesNo Other, please specify: Medication and treatment 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.)YesNo Med 1 Medication, Vitamin or supplement name Dosage Frequency 1,2,3,4 Timing Check box to add additional medication Med 2 Medication, Vitamin or supplement name Dosage Frequency Timing Check box to add additional medication Med 3 Medication, Vitamin or supplement name Dosage Frequency Timing Check box to add additional medication Med 4 Medication, Vitamin or supplement name Dosage Frequency Timing Check box to add additional medication Med 5 Medication, Vitamin or supplement name Dosage Frequency Timing Check box to add additional medication Med 6 Medication, Vitamin or supplement name Dosage Frequency Timing Check box to add additional medication Med 7 Medication, Vitamin or supplement name Dosage Frequency Timing Check box to add additional medication Med 8 Medication, Vitamin or supplement name Dosage Frequency Timing Check box to add additional medication Med 9 Medication, Vitamin or supplement name Dosage Frequency Timing Check box to add additional medication Med 10 Medication, Vitamin or supplement name Dosage Frequency Timing List any additional medications, dosages, frequency and timing here. Provider information Primary Insurance Provider Are you currently enrolled in Medicare?YesNo Are you currently enrolled in Medicaid?YesNo Please select all the healthcare providers you have access to: Primary DoctorYesNo Eye DoctorYesNo Foot DoctorYesNo Ear DoctorYesNo DentistYesNo Physical TherapistYesNo Mental Health ProviderYesNo Regional Center If you currently receive services from a Regional Center, please select one from this list. If you do not receive services from any of them, please select "N/A." Waivers, Releases and Policies Please read the following information and fully before signing this form.I agree to the following for Special Olympics Northern California and related programs:Athlete Code of Conduct. I agree to all portions of the Athlete Code of Conduct which I can read in full here.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.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.Overnight Stay. For some events, overnight accommodations may be required. If I have questions, I will contact my Special Olympics Program.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.”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 further understand that Special Olympics may use personal information for the following: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.for communicating with me about Special Olympics programs.for sharing 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 understand that I have the right 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.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 indicate be selecting "No" below: Medical treatment acceptance or refusalYes, I agree to accept medical treatment in an emergency, including brood transfusions and other treatment, as neededNo, I refuse medical treatment for religious or other reasons Emergency Medical Care Refusal Form EMERGENCY MEDICAL CARE REFUSAL FORM – ATHLETE COMPLETION By selecting "No" to the preceding question, and by signing and submitting this document, you are acknowledging and agreeing to the following regarding refusal of care: I am a Special Olympics athlete with capacity to sign documents on my own behalf, or I am a parent/guardian submitting on behalf of an athlete, and agree to the following:No Consent to Emergency Medical Care. I understand that Special Olympics’ standard registration form requires athletes, or their parents or guardians, to consent to 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 and/or blood transfusions, per answers on preceding portion of form.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.Friend or Family Accompaniment. I understand that I must be accompanied by an adult friend or family member to all SONorCal practices, competitions, and events, in order for that person to take personal responsibility for me during a medical emergency when I may be unable to speak for myself. I also understand I will be ineligible to travel overnight to SONorCal events unless accompanied by a parent/guardian who is also a registered SONorCal volunteer.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.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. 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 & 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: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;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,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. Athlete Agreement By checking this box, I attest that I have read the above waivers, releases, and policies, and acknowledge and agree to them Athlete Name Please use full name; applications without full legal names cannot be processed By checking this box, I attest that the above field contains my signature Parent/Guardian Agreement - by signing here, I recognize, and agree to, statements on this page By checking this box, I attest that: first, I am legally able to sign on behalf of the applicant, and second, that I have read the above waivers, releases, and policies, and acknowledge and agree to them Parent/Guardian Name Please use full name; applications without full legal names cannot be processed. By checking this box, I attest that the above field contains my signature Have Questions? Get in touch with Special Olympics NorCal! Send us your questions or comments and we’ll respond shortly. Don’t forget to sign up for the newsletter! 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