Microsoft word - 3c9bc918-4cd3-c2d8.doc

Athlete Application for Participation
(Valid for 3 Years from the Date of the Physical Exam)
Please print clearly. All information is required.
Social Security Number (optional) Male Female Date of Birth Phone # Last Name, First Name:

HEALTH HISTORY: TO BE COMPLETED BY PARENT/CAREGIVER
Yes No
Date of last tetanus immunization _____/_____/_____ Needs medication (see “Medications” table below) __________________________________________________ (*) Requires physical examination if new problem
Medications (if applicable): Please print medication name, amount, date prescribed and number of times per day medication is given.
Medication Name
Special Olympics Massachusetts (SOMA) specifically has my permission (both during participation and anytime thereafter) to use my/my child’s/my ward’s likeness, name, voice, and words in television, radio, film, newspaper, magazines, and any other media, and in any form, for the purpose of advertising or communicating the purposes and activities of Special Olympics Massachusetts. Form Expiration Date
I understand that if a medical emergency should arise during my/my child’s/my ward’s participation in any SOMA activity and I am not able to give my consent for treatment, that SOMA is authorized to take whatever measures are necessary to protect my health and well-being including hospitalization. Signature of parent/legal guardian/adult athlete (over 18) SECTIONS BELOW TO BE COMPLETED BY EXAMINING PHYSICIAN:

For Athletes With Down Syndrome: Persons with Down syndrome should have a lateral x-ray of the cervical spine in
hyper flexion and hyperextension. The interpretation of the radiographs should include measurements of the atlanto-dens interval.
Yes No
Has an x-ray evaluation for atlantoaxial instability been done? Date of x-ray: ______/______/______ If yes, was it positive for atlantoaxial instability? (positive indicates that the atlanto-dens interval is 5mm or more) I have reviewed the above health information and have performed the above examination on this athlete within the past 6 months and certify that the athlete can participate in Special Olympics. RESTRICTIONS:
(no office stamps accepted without provider’s signature) A COPY OF THIS APPLICATION MUST BE FILED AT THE SOMA HEADQUARTERS & EITHER THE AREA OR SECTIONAL OFFICE 3/02
COACHES WILL BE RESPONSIBLE FOR HAVING UP-TO-DATE ATHLETE
MEDICAL FORMS IN THEIR POSSESSION AT TRAINING AND COMPETITION
EVENTS. THE COACH’S COPIES OF MEDICAL FORMS WILL BE UTILIZED AT ALL
QUALIFYING COMPETITIONS AND AREA EVENTS.


Medical forms are evaluated for completeness using the following required information as criteria:
on the correct form area and local program full first and last name gender date of birth street address city home phone number, including area code parent/guardian name (if under 18) emergency contact name and phone number, including area code signature of athlete (18 or older) or signature of parent/guardian "history of" medical information on the medical unless supplemented by an attachment which contains the doctor's/physician’s assistant/nurse practitioner’s signature (no office stamps allowed) date of physical examination no fax copies accepted OVERNIGHT EVENTS
If medication is to be dispensed by SOMA medical volunteers, it must be accompanied by a medication form Medication must be in its original container

Source: http://www.hopkintonspecialolympics.org/Medical%20Form.pdf