Athlete Application & Medical Upload - Special Olympics CO

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About Special Olympics Colorado

The mission of Special Olympics is to provide year-round sports training and athletic competition in a variety of Olympic-type sports for children and adults with intellectual disabilities, giving them continuing opportunities to develop physical fitness, demonstrate courage, experience joy and participate in a sharing of gifts, skills and friendship with their families, other Special Olympics athletes and the community.

Info@SpecialOlympicsCO.org

12450 E Arapahoe Rd Suite C
Centennial, CO 80112

Office hours:
Monday – Friday 8:30am – 5:00pm

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Athlete Application & Medical Upload

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Athlete Application & Medical Upload

Special Olympics Colorado Online Athlete Application!

*Required for participation as an athlete

A few important items before proceeding:

Physical Exam: In order to submit this application you will be asked to upload a copy of your physical exam that has been completed and signed by a licensed physician/medical provider, is dated and gives the athlete permission to participate in sports/Special Olympics.
1. If you do not have this medical exam please come back when you have the completed copy to upload.
  - Click here to view the English version of the Medical Exam
  - Click here to view the Spanish version of the Medical Exam
Web Browser: Make sure you are using the Chrome web browser (other web browsers are not recommended and may cause difficulties).
Save & Continue: You can save your application and come back later by clicking “Save & Continue Later” and entering an email address. You will receive a link to your saved application which is good for 30 days.
Email Confirmation: You will receive a copy of your submitted application upon submission. There are also opportunities to add in email addresses for others you would like to receive a copy.
NEED HELP? If you are having trouble or have any questions please visit our Application Resources by clicking here.

1Welcome

2Physical Exam Upload, Athlete Information & Health History

3Waivers, Release Forms and Signatures

4

5

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Special Olympics Colorado (SOCO) Athlete Application & Physical Exam Upload

Has participant been diagnosed with an Intellectual Disability/Delay/Disorder?(Required)

What is Intellectual Disability?

Yes

No

To become a Unified Partner, please complete the application linked below:

In order to proceed with the application, you will be required to upload the sports physical exam that has been completed by a licensed physician.(Required)

Yes, I have a copy of my completed Sports Physical Exam ready to upload - It is signed, dated and clears the athlete for participation in SOCO

No, I do not have a copy of my completed Physical Exam ready for upload

Please Return When You Have a Copy of Your Physical Exam to Upload.

Physical Examination Form - English
Physical Examination Form - Spanish

What is the Exam Date written by the doctor on the sports physical?(Required)

If no date is provided, please have doctor fill in the exam date before uploading the file.

MM slash DD slash YYYY

Upload Athlete Physical Examination Form Here(Required)

If you DO NOT have the Physical Exam to upload, please save and come back when you have it to upload.

Drop files here or

Max. file size: 300 MB.

This field is hidden when viewing the form

EXAMUPLOAD(Required)

If you DO NOT have the Physical Exam to upload, please save and come back when you have it to upload.

Max. file size: 300 MB.

Is the Athlete:(Required)

18 Years or Older & Is Their Own Guardian

Under age 18 OR Over 18 and NOT their own Guardian

Are you a new Athlete to Special Olympics Colorado or Re-Registering?(Required)

New

Renewing Application

Name(Required)

First Middle Last

Preferred/Nickname

Race / Ethnicity (select all that apply)(Required)

American Indian/Alaskan Native

Asian American

Black or African American

Hispanic or Latinx

Native Hawaiian or Other Pacific Islander

White or Caucasian

Prefer not to answer

Other / More than One

If other Race/Ethnicity, please list:

Language(s) Spoken (select all that apply)(Required)

English

Spanish

Other

If other language, please list:

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

Other

Other Gender(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

What County does the athlete live in?(Required)

Athlete Email(Required)

Enter Email Confirm Email

Phone(Required)

Athlete Employer (optional)

Coach Name(s) If Known

Parent / Guardian Information

Parent / Guardian Name

Required if minor or otherwise has a legal guardian. If the athlete is not his or her own guardian, please list the name of the person who makes legal and medical decisions for the athlete.

First Last

Relationship to Athlete

Address

Same as athlete address listed above

Street Address Address Line 2 City State ZIP Code

Parent / Guardian Email

Enter Email Confirm Email

Phone

Would you like your parent/guardian to receive a copy of this application upon completion?

Yes

No

Would you like to add a second parent/guardian?

Yes

No

Second Parent/Guardian Name

First Last

Second Parent/Guardian Address

Same as athlete address listed above

Street Address Address Line 2 City State ZIP Code

Second Parent/Guardian Email

Phone

Relationship to Athlete

Would you like your second parent/guardian to receive a copy of this application upon completion?

Yes

No

Emergency & Medical Contacts

Emergency Contact Name(Required)

First Last

Relationship to Athlete(Required)

Emergency Contact Email(Required)

Phone(Required)

Would you like your emergency contact to receive a copy of this application upon completion?

Yes

No

Physician & Insurance Information

Primary Physician Name

List the name, phone number and address of the athlete's primary care physician. This may be different from the name of the physician performing the pre-participation physical. Also list the insurance information if the athlete has insurance, including Medicaid or Medicare.

First Last

Physician Phone

Insurance Company(Required)

Examples: Medicaid, Medicare, Kaiser, etc.

Insurance Policy Number

Insurance Group Number

Name of Secondary Insurance (if applicable)

Does the athlete have: (select all that apply)(Required)

If the athlete has any other diagnosis, syndrome or condition not listed below, please list it in the box marked "Other".

Autism

Cerebral Palsy

Down Syndrome

Fetal Alcohol Syndrome

Fragile X Syndrome

Other

Please specify:(Required)

Current Health Status

Has a doctor ever limited the athlete's participation in sports?(Required)

Note if any doctor has ever prohibited the athlete from participating in sports for any medical reason. If so, specify the reason.

Yes

No

If yes, please describe:(Required)

Allergies & Dietary Restrictions

Specify any food, medication or latex allergies that the athlete may have. If the athlete has no allergies, mark "No Known Allergies"

No Known Allergies

No Known Allergies

Latex(Required)

Yes

No

Medications(Required)

Yes

No

If yes, please specify which medications athlete is allergic to:(Required)

Insect Bites/Stings(Required)

Yes

No

If yes, please specify which insect bite/sting(s) athlete is allergic to:(Required)

Food(Required)

Yes

No

If yes, please specify which food(s) athlete is allergic to:(Required)

List any special dietary needs

For example: Gluten free diet, vegetarian, lactose free, peanut free, or any religious diet preferences.

Surgeries, Infections, Vaccines

Has the athlete had any past surgeries?(Required)

Yes

No

List all past surgeries:

List any past surgeries that the athlete has had, WHY the athlete had the surgery and WHEN. It is especially important to note surgeries involving the heart, lungs, brain or spine.

Does the athlete currently have any chronic or acute infections?(Required)

Yes

No

If yes, please describe, including treatment:(Required)

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

Yes, had abnormal EKG

Yes, had abnormal Echo

No

If yes, please describe:(Required)

Include abnormality, date and results

Assistive Devices

Does the athlete use: (select all that apply)

Brace

C-Pap Machine

Glasses or Contacts

Implanted Device

Removable Prosthetics

Colostomy

Crutches or Walker

G-Tube or J-Tube

Inhaler

Splint

Communication Device

Dentures

Hearing Aid

Pacemaker

Wheelchair

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

This is also sometimes called a DTaP or DTP vaccine. If not, the athlete may be required to obtain a vaccine prior to participation, specifically for World Games.

Yes

No

Has the athlete been fully vaccinated against COVID-19?

Fully vaccinated = 2 doses of Pfizer or Moderna and 1 dose of Johnson & Johnson

Yes

No

Prefer not to answer

Family Health History

Family history includes close relatives such as a parent, grandparent, aunt, uncle, brother, sister or cousin.

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

Yes

No

Has any family member or relative died while exercising?(Required)

Yes

No

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

It is especially important to note any genetic, neurological (brain), or cardiac (heart) conditions.

Past Diagnosis

Has the athlete ever been diagnosed with or experienced any of the following conditions? (select all that apply)

Loss of Consciousness

Dizziness during or after exercise

Headache during or after exercise

Chest pain during or after exercise

Shortness of breath during or after exercise

Irregular, racing or skipped heart beats

Congenital Heart Defect

Heart Attack

Cardiomyopathy

Heart Valve Disease

Heart Murmur

Endocarditis

High Blood Pressure

High Cholesterol

Vision Impairment

Hearing Impairment

Enlarged Spleen

Single Kidney

Osteoporosis

Osteopenia

Sickle Cell Disease

Sickle Cell Trait

Easy Bleeding

Stroke/TIA

Concussions

Asthma

Diabetes

Hepatitis

Urinary Discomfort

Spina Bifida

Arthritis

Heat Illness

Broken Bones

Dislocated Joints

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

Neurological Symptoms for Spinal Cord Compression & Atlanto-axial Instability:

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

Difficulty controlling bowels or bladder(Required)

Yes

No

If yes, is this new or worse in the past 3 years?(Required)

Yes

No

Numbness of tingling in legs, arms, hands or feet(Required)

Lack of feeling of a feeling like "pins and needles"

Yes

No

If yes, is this new or worse in the past 3 years?(Required)

Yes

No

Weakness in legs, arms, hands, or feet(Required)

Yes

No

If yes, is this new or worse in the past 3 years?(Required)

Yes

No

Burner, stinger, pinched nerve or pain in the neck, back, shoulders, arms, hands, buttocks, legs, or feet(Required)

A burning or stinging feeling

Yes

No

If yes, is this new or worse in the past 3 years?(Required)

Yes

No

Head Tilt(Required)

When the head often tilts/leans to one side

Yes

No

If yes, is this new or worse in the past 3 years?(Required)

Yes

No

Spasticity(Required)

Spasticity is a constant stiffness or tightness of the muscles that can impact normal movement, speech or walking stride.

Yes

No

If yes, is this new or worse in the past 3 years?(Required)

Yes

No

Paralysis(Required)

The loss of the ability to move (and sometimes to feel anything) in part or most of the body.

Yes

No

If yes, is this new or worse in the past 3 years?(Required)

Yes

No

Epilepsy and/or Seizure History

Has the athlete ever been diagnosed with / experienced Epilepsy or any other type of seizure disorder?(Required)

Yes

No

If yes, list seizure type:(Required)

If yes, had seizure during the past year?(Required)

Yes

No

Mental Health

Has the athlete been diagnosed with or experienced: (select all that apply)

*Self Injurious behavior may include hitting or hurting themselves. *Aggressive behavior may include hitting or hurting others physically or verbally

Self-Injurious behavior during the past year

Aggressive behavior during the past year

Depression (diagnosed by a doctor)

Anxiety (diagnosed by a doctor)

Describe any additional mental health concerns:

List any other mental health concerns such as ADHD, schizophrenia, bipolar, psychosis that the athlete has currently or has had in the past.

Other

List any other ongoing or past medical conditions:

List any other past or ongoing medical conditions for which the athlete required or currently requires treatment which have not been included in other places on this form.

Current Medications, Vitamins & Dietary Supplements

Is the athlete currently taking any medications, vitamins or dietary supplements?(Required)

Yes

No

List any current medication, vitamins or dietary supplements below(Required)

Including inhalers, birth control, hormone therapy, prescription drugs, over the counter (drugstore) medications, vitamins, herbal supplements.

Medication, Vitamin or Supplement Name:

Dosage

Times per Day

Is the athlete able to administer their own medications?(Required)

Is the athlete able to take medications by themself without reminders or assistance.

Yes

No

Athlete Release Form

I want to take part in Special Olympics and agree to the following:

1. ABILITY TO PARTICIPATE: I am physically able to take part in Special Olympics / Special Olympics Colorado activities.

2. LIKENESS RELEASE: I give permission to Special Olympics, Inc., Special Olympics games organizing committees, and Special Olympics accredited Programs (collectively “Special Olympics”) to use my likeness, photo, video, name, voice, words, and biographical information to promote Special Olympics and raise funds for Special Olympics.

3. RISK OF CONCUSSION & OTHER INJURY: I know there is a risk of injury. I understand the risk of continuing to play sports with or after a concussion or other injury. I may have to get medical care if I have a suspected concussion or other injury. I also may have to wait 7 days or more and get permission from a doctor before I start playing sports again. CONCUSSION POLICY: https://bit.ly/ConcussionSafety22

4. 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:

TO REFUSE EMERGENCY MEDICAL CARE check one of the boxes below. NOTE: If either box is marked, an EMERGENCY MEDICAL CARE REFUSAL FORM must be completed and carried with athlete at all times.

TO REFUSE EMERGENCY MEDICAL CARE check one of the boxes below. NOTE: If either box is marked, an EMERGENCY MEDICAL CARE REFUSAL FORM must be completed and carried with athlete at all times.

I have a religious or other objection to receiving medical treatment. (Not Common)

I do not consent to blood transfusions. (Not Common)

Emergency Medical Exemption(Required)

Based on your previous response you indicated that you REFUSE EMERGENCY MEDICAL CARE.

I understand I must complete and carry an Emergency Medical Care Refusal Form (Document will be emailed separately)

5. OVERNIGHT STAYS: For some events, I may stay in a hotel or someone’s home. If I have questions, I will ask.

6. HEALTH PROGRAMS: If I take part in a health program, I consent to health activities, exams, and treatment. This should not replace regular health care. I can say no to treatment or anything else any time.

7. 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 SPECIAL OLYMPICS TO:

a). 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.

b). using my contact information for communicating with me about Special Olympics.

c). 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.

I Agree(Required)

I have read, understand and agree to everything listed above. If I have questions, I will ask. By signing below, I agree to this form.

SPONSOR LIKENESS RELEASE:(Required)

I give permission to Special Olympics, Inc., Special Olympics games organizing committees, and Special Olympics accredited Programs (collectively “Special Olympics”) and their sponsors and partners to use my likeness, photo, video, name, voice, words, and biographical information (“my likeness”) to acknowledge the sponsors’ and partners’ support for Special Olympics. Special Olympics and its sponsors and partners will not use my Likeness to endorse commercial products or services. I understand I will not be compensated for the use of my Likeness.

I Agree

I Do Not Agree

Waiver and Release of Liability, Assumption of Risk and Indemnification Agreement for Communicable Diseases for Special Olympics Colorado

In consideration of being allowed to participate in any way in Special Olympics sports training, competition or fundraising activities, the undersigned acknowledges, appreciates, and agrees that:

1. Participation includes possible exposure to and illness from infectious and/or communicable diseases including but not limited to MRSA, influenza, and COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist; and,

2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,

3. I willingly agree to comply with the stated and customary terms and conditions for participation as regards protection against infectious diseases. If, however, I observe and 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 official immediately; and,

4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS Special Olympics, Inc, Special Olympics Colorado their officers, officials, agents, and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event (“RELEASEES”), WITH RESPECT TO ANY AND ALL ILLNESS, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

I HAVE READ THIS COMMUNICABLE DISEASES WAIVER & RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IF FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.(Required)

I Agree

FOR ATHLETES OF MINORITY AGE (UNDER AGE 18 AT THE TIME OF REGISTRATION) OR "NOT THEIR OWN GUARDIAN": This is to certify that I, as parent/guardian, with legal responsibility for this participant, have read and explained the provisions in this waiver/release to my child/ward including the risks of presence and participation and his/her personal responsibilities for adhering to the rules and regulations for protection against communicable diseases. Furthermore, my child/ward understands and accepts these risks and responsibilities. I for myself, my spouse, and child/ward do consent and agree to his/her release provided above for all the Releasees and myself, my spouse, and child/ward do release and agree to indemnify and hold harmless the Releasees for any and all liabilities incident to my minor child’s/ward’s presence or participation in these activities as provided above, EVEN IF ARISING FROM THEIR NEGLIGENCE, to the fullest extent provided by law.(Required)(Required)

I Agree

Signatures

Athlete Name(Required)

First Last

Athlete Signature (required for adult athlete with capacity to sign legal documents)(Required)

I have read and understand this athlete application/form. If I have questions, I will ask. By signing, I agree to this application/form.

Parent / Guardian Signature(Required)

Required for athlete who is a minor or lacks capacity to sign legal documents.

First Last

Relationship to Athlete(Required)

Parent / Guardian Signature(Required)

I am a parent or guardian of the athlete. I have read and understand this athlete application/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.

Today's Date

MM slash DD slash YYYY

Upon submission, you will receive a copy of this application. Would you like anyone else to receive a copy of YOUR application via email? (e.g. a coach, parent)

NOTE: This application contains personal information so be cautious when deciding who will receive a copy.

Yes

No

Email a copy of this application here:(Required)

Enter email address of person you wish to receive a copy of this application.

Is there another person you would like to receive an emailed copy of YOUR application? (e.g. coach, parent)

NOTE: This application contains personal information so be cautious when deciding who will receive a copy.

Yes

No

Email another copy of this application here:(Required)

Enter email address of person you wish to receive a copy of this application.

File

Max. file size: 300 MB.

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