Athtetes" Registration

Young
60

s u',i,?,ifl'I,:

Form

ii:';,1'u,-,682

309-888-2

55

SO ILL Rev 8-1-201 4

"inil:i
Athlete's Name

(LastlFamity)

Parent/Guardian Name:
(First/Civen)

Add ress:

(FirsllC'iven)

City:

State:_

Zip Code

Birth Date: Month_-...--

Home Phone:

Day_

Cet[ Phone:

Year_

Gender: OMate OFemate

Emai[:

Secondary Contact Name:

Phone:

Basic Health Information:

Heart Probtems fl Yes fl No
D ia be[ic
CYes n No
Epiteptic lseizure fl Yes fl No

Btind il Yes n
Deat nYes n
HepaLitis C Yes n
DownSyndrome O Yes D No tFYes-----)CtearAAl -t yes 0
O th

(LastlFamity)

er:

No
No
No
No

Atterg ies:

Ethnicity: D White O Black/AFrican American D Asian -l Hispanic/Latino D Other

Young Athlete is being registered as a: O TraditionatYoung Aihtete (with Intettectuat Disabitity)

Peer Partner (without

In

tetlectuaI Disabitity)

Young Athletes Release Form

I am the parent/guardian oF the minor participant, on whose behalf I have submitted the attached apptication for participation in Special Otympics.
The p_articipant has my permission to participate in Speciat olympics activities. I further represent and warrant that to the best of my knowlidge and
belief, the participant is physically and mentatly abte to participate in Specia[ Otympics.

In permitting the participant to participate, lam specificatly granting my permission to Special otympics to use the participant's likeness, voice and
words in television, radio, titm, newspapers, magazines and other media, and in any form, tor the purpose of pubticizing, promoting or communicating
the purposes and activities of.Special Otympics and/or apptying For funds to support those purposes and activities. I atio understand that group data
cotlected from the Young Athleles Program will be used to plan, evaluate, and improve the program.

lf a medical emergency should arise during the participant's participation in any SpeciatOtympics activities, at a time when I am not personatty present
so as to be consulted regarding the participant's care, I hereby authorize SpeciaI otympics, on my behatl to take whatever measures are necessary to
ensure that the participant is provided with any emergency medicat treatment, inctuding hospititization, which Speciat otympics deems advisabte in
order to protect the participant's heatth and well-being. (lF YOU HAVE RELtGIOUS OBJECTTONS TO RECEtVtNG SUCH MEDICAL TREATMENT,
PLEASE CONTACT SpEC|AL OLyMplcs tLLtNots - MANAGER OF yOUNG ATHLETES)
I am the parenl (guardian) oF the participant named in this apptication. I have read and futty understand the provisions of the above retease, and have
explained these provisions !o the participant. Through my signature on this retease Form, I am agreeing to the above provisions on my own behatf and
on the behalf of the Participant named above. I hereby give my permission for the participant nJmed above to participate in Speciat 6tymprcs games,
recreaLion programs, and physicat activity programs.

Signature of Paren tl0uardian

Prin t Na me
OriginaI parent/guardian signature is required by the office oF SpeciaI Otympics lltinois.

Da

te

FORM VALID UNTIL INDIVIDUALS NINETH BIRTHDAY WITH CONTINUED PARTICIPATION

Program InFormation (To Be Completed By Site Coordinator)

A program may have multipte sites. Site is defined as the speciFic location
Young Athtete site this chitd witl attend is (Setect one of the fottowing.)
El A group site - Speciat olympics lltinois

Agency Name

_SW

the Young Athtetes Aclivities. The

At home (imptemented by you or a Family member at home)

CO-OP

SchooI Name_Ridge
Ctass Time:

Agency

oF

nAM nPM IIALL

Teacher

DAY

Name 11o1h1 -To ,alira J ofr\

Agency SOAD/S|Le Coordinator

*,