United States Form

Athlete Registration
Emergency and Medical Contacts
Sport Interest
Current Health Status
Family Health History
Past Diagnosis
Neurological Symptoms
Current Medications
Submit & Sign

Athlete Registration

* indicates required

State Program^*

Local Area/Delegation^*

Are you a new athlete to Special Olympics or Re-registering?

New Athlete

Re-Registering

Athlete Information

First Name^*

Middle Name

Last Name^*

Preferred Name

Date of Birth ^*

Address (Street)^*

City^*

State^*

Postal Code^*

Phone

Email Address^*

Gender^*

Male

Female

Other

Race/Ethnicity^*

Language (select all that apply) (optional)

English

Spanish

Other (Please List)

If other language, please list:

Athlete Employer (optional)

Does the athlete have the capacity to consent to medical treatment on his or her own behalf?^*

Yes

Parent & Guardian

Required if minor or otherwise has a legal guardian

Name

Relationship

Same contact info as Athlete?

Yes

Address (Street)

City

State

Zip Code

Phone

Email Address

Emergency and Medical Contacts

* indicates required

Is emergency contact same as parent or guardian?^*

Yes

Emergency Contact Name^*

Emergency Contact Phone^*

Emergency Contact Relationship to Athlete^*

Physician Name

Physician Phone

Insurance Company

Insurance Policy Number

Insurance Group Number

Sport Interest

* indicates required

Select any sports that the athlete wishes to play^*

Add Another Sport

Please list any other sports that may not have been included above.

Has a doctor ever limited the athlete's participation in sports?^*

Yes

If yes, please describe:

Current Health Status

* indicates required

Does the athlete have:

Autism

Down Syndrome

Fragile X Syndrome

Cerebral Palsy

Fetal Alcohol Syndrome

Other

Please specify:

Allergies & Dietary Restrictions

Is the athlete allergic to any of the following:

No Known Allergies

Latex

Medications

Insect Bites or Stings

Food

If allergic to medications, please specify:

If allergic to insect bites or stings, please specify:

If allergic to food, please specify:

List any special dietary needs:

Assisted Devices

Does the athlete use: (select all that apply)

Brace

Colostomy

Communication Device

C-PAP Machine

Crutches or Walker

Dentures

Glasses or Contacts

G-Tube or J-Tube

Hearing Aid

Implanted Device

Inhaler

Pacemaker

Removable Prosthetics

Splint

Wheelchair

Surgeries, Infections, Vaccines

List all past surgeries:

Does the athlete currently have any chronic or acute infections?^*

Yes

If yes, please describe:

Has the athlete ever had an abnormal Electrocardiogram (EKG) or Echocardiogram (Echo)?^*

Yes, had abnormal EKG

Yes, had abnormal Echo

If yes, please describe:

Has the athlete had a Tetanus vaccine in the past 7 years?

Yes

Epilepsy and/or Seizure History

Has the athlete ever been diagnosed with or experienced:

Epilepsy or any other type of seizure disorder^*

Yes

If yes, had seizure during the past year?

Yes

If yes, list seizure type

Mental Health

Has the athlete been diagnosed with or experienced:

Self-Injurious behavior during the past year?^*

Yes

Aggressive behavior during the past year?^*

Yes

Depression (diagnosed)^*

Yes

Anxiety (diagnosed)^*

Yes

Describe any additional mental health concerns:

Family Health History

* indicates required

Has any relative died of a heart problem before of age 50?

Yes

Has any family member or relative died while exercising?

Yes

List all medical conditions that run in the athlete's family:

Past Diagnosis

* indicates required

Has the athlete ever been diagnosed with or experienced any of the following conditions:

Loss of Consciousness^*

Yes

Dizziness during or after exercise^*

Yes

Headache during or after exercise^*

Yes

Chest Pain during or after exercise^*

Yes

Shortness of breath during or after exercise^*

Yes

Irregular, racing or skipped heart beats^*

Yes

Congenital Heart Defect^*

Yes

Heart Attack^*

Yes

Cardiomyopathy^*

Yes

Heart Valve Disease^*

Yes

Heart Murmur^*

Yes

Endocarditis^*

Yes

High Blood Pressure^*

Yes

High Cholesterol ^*

Yes

Vision Impairment^*

Yes

Hearing Impairment^*

Yes

Enlarged Spleen^*

Yes

Single Kidney^*

Yes

Osteoporosis^*

Yes

Osteopenia^*

Yes

Sickle Cell Disease^*

Yes

Sickle Cell Trait^*

Yes

Easy Bleeding ^*

Yes

Stroke/TIA^*

Yes

Concussions^*

Yes

Asthma^*

Yes

Diabetes^*

Yes

Hepatitis^*

Yes

Urinary Discomfort ^*

Yes

Spina Bifida^*

Yes

Arthritis^*

Yes

Heat Illness^*

Yes

Broken Bones^*

Yes

Dislocated Joints^*

Yes

Describe any past broken bones or dislocated joints if selected yes above

List any other ongoing or past medical conditions

Menstrual Period

Neurological Symptoms

* indicates required

Has the athlete ever been diagnosed with or experienced any of the following conditions:

Difficulty controlling bowels or bladder^*

Yes